1.2 planning, design, construction, and commissioning€¦ · commissioning of building water...

1.2 Planning, Design, Construction, and Commissioning

DRAFT 2022 FGI Guidelines for Design and Construction of Hospitals 1


Appendix material, intended to be advisory only, is offset and begins with the letter “A” following the

corresponding requirement.

*1.2-1 General

A1.2-1.1 Planning, design, and implementation process. To meet the

objectives of this chapter, health care organizations should develop an

interdisciplinary design process to guide facility design. The intent of an

interdisciplinary design process is to improve building performance by

integrating sustainable design considerations from project inception.

*1.2-1.1 Application

The provisions of this chapter shall apply to all hospital projects.

*1.2-1.2 Multidisciplinary Project Team

*1.2-1.2.1 Project Team

To meet the objectives of this chapter, M multidisciplinary groups/persons (stakeholders) affected by and

integral to the design shall be identified. included in the project planning and implementation process.

A1.2-1.2.1 Project team

a. The multidisciplinary project team should be assembled as early as possible in

the design process.

b. The multidisciplinary team should include administrators, clinicians, infection

preventionists, architects and other design professionals, facility managers, safety

officers, security managers, information technology specialists, users of

equipment, and support staff relevant to the areas affected by the project as well

as those with knowledge of the organization’s functional goal for the project.

Inclusion of patient advocates/consumers, A/E consultants,

environmental/occupational health specialists, and construction specialists should

be considered.

c. The multidisciplinary team should be included throughout the project

development and implementation processes.

1.2-1.2.2 The scope and nature of the project shall dictate the diversity of others to be involved on the

project multidisciplinary team.

*1.2-1.3 Environment of Care and Facility Function Considerations

A1.2-1.3 Environment of care and facility function considerations. Described

in Section 1.2-5 (Environment of Care Requirements) are environment of care

components (including key elements of the physical environment) and functional

facility requirements that directly affect the experience of all people who spend

time in hospitals. How these components and requirements are addressed in

hospital design influences patient care outcomes and patient satisfaction, dignity,

privacy, confidentiality, and safety as well as the incidence of medical errors,



patient and staff stress, and facility operations.

In addition to the text in this chapter, which applies to all hospitals, specific

elements of the environment of care are described in individual chapters where

the demonstrated value and necessity of such features are unique to a particular

facility type.

*1.2-1.3.1 Framework for Hospital Design

A1.2-1.3.1 Framework for hospital design. The care environment is defined as

those features in a health care facility that are designed, built, and maintained to

support quality health care. As patients and their families are becoming more

involved in the course of care, health care organizations need to respond to the

changing requirements for accommodations.

a. The health care environment should enhance the dignity of the patient through

features that permit privacy and confidentiality.

b. Stress can be a major detriment to the course of a patient’s care. The facility

should be designed to reduce patient, family, and staff stress wherever possible.

Research and evidence-based materials are available to support these goals and

should be referred to during design.

c. As technology changes, flexibility is in the best interests of quality care.

d. Health care economics continuously apply pressure to management. Therefore,

every effort should be made during the design process to enhance the

performance, productivity, and satisfaction of staff to promote a safe

environment of care.

e. Creativity should be encouraged in the design process to enhance the

environment of care.

1.2-1.3.1.1 Because the built environment has a profound effect on health, productivity, and the natural

environment, hospitals shall be designed within a framework that recognizes the primary mission of

health care (including “first, do no harm”) and that considers the larger context of enhanced patient

environment, employee effectiveness, and resource stewardship.

*1.2-1.3.1.2 Hospital planning, design, construction, and commissioning activities shall include—in

addition to consideration of space and operational needs—consideration of components in the safety risk

assessment (see Section 1.2-4, Safety Risk Assessment) as well as life safety and protection of occupants

during construction.

A1.2-1.3.1.2 Facility construction, whether for freestanding buildings or

expansion or renovation of existing buildings, can create conditions that are

harmful to patients and staff. Thus, new health care buildings and renovations

should be designed and constructed to facilitate ongoing cleanliness and mitigate

infection control concerns.

1.2-2 Functional Program

1.2-2.1 General



*1.2-2.1.1 Functional Program Purpose

1.2-2.1.1.1 The primary purpose of the functional program shall be to communicate the owner’s intent for

the project to the designers of record as a basis of design at the initiation of the project.

A1.2-2.1.1.1 Functional program purpose

a. All projects, large and small, require a functional program to guide the design.

The length and complexity of the functional program will vary greatly depending

on project scope. The functional program for a small, simple project might

consist of a simple sketch or a description of a few sentences.

b. The functional program can be used as a supplement to the construction

documents; it is not intended to be approved by the authority having jurisdiction

(AHJ).

1.2-2.1.1.12 The functional program shall be used to determine the application of the Guidelines when

developing facility projects.

1.2-2.1.2 Functional Program Requirement

*1.2-2.1.2.1 The governing body of the health care organization shall be responsible for having a

functional program developed, documented, and updated.

A1.2-2.1.2.1 The governing body may delegate documentation of the functional

program to the architect or another consultant.

1.2-2.1.2.2 A functional program shall be developed for new construction, major renovations, and

projects that change the functional use of any hospital space.

(1) The functional program shall be completed as part of the project planning phase and updated, as

needed, throughout the design and construction phases.

(2) Following its approval, the functional program shall serve as the basis for the project design and

construction documents.

1.2-2.1.2.3 The facility shall retain the functional program with other design data to facilitate future

alterations, additions, and program changes. [Moved from 1.2-2.1.1.2]

1.2-2.1.2.34 Activities such as equipment replacement, fire safety upgrades, or minor renovations that

will not change the facility’s function or character shall not require a functional program.

1.2-2.1.3 Nomenclature in the Functional Program

1.2-2.1.3.1 The names for spaces and departments used in the functional program shall be consistent with

those used in the Guidelines for Design and Construction of Hospitals. If acronyms are used, they shall be

clearly defined.

1.2-2.1.3.2 The names and spaces indicated in the functional program also shall be consistent with those

used on submitted floor plans.

1.2-2.2 Functional Program Content

The functional program for a project shall include the following:



1.2-2.2.1 Functional Program Executive Summary

An executive summary of the key elements of the functional program shall be provided and, at minimum,

shall include the information outlined in Section 1.2-2.2 (Functional Program Content) in a project

narrative.

*1.2-2.2.2 Purpose of the Project

Services to be provided, expanded, or eliminated by the proposed project shall be described.

A1.2-2.2.2 Project purpose

a. The completed functional program should describe in detail the governing

body’s overall project requirements.

b. The functional program should provide the following information for the

project, consistent with the governing body’s expectations for delivery of care

and project scope:

—Who will be served by the project (e.g., patients, family members, staff)

—What user activities and functions will occur in the spaces created or affected

by the project

—How each user group is engaged in each activity or function

—When each activity or function will take place in terms of time of day and/or

step in process

—Where each activity or function will take place

—What resources are required to support each activity or function including but

not limited to people, equipment, supplies, and related processes.

1.2-2.2.3 Project Type and Size

1.2-2.2.3.1 The type of hospital proposed for the project shall be identified as defined by the Guidelines.

1.2-2.2.3.2 Project size in square footage (new construction and/or renovation) and number of stories shall

be provided.

*1.2-2.2.3.3 The patient population and required staff for the building design shall be identified.

A1.2-2.2.3.3 Patient population. Identifying the patient population provides an

opportunity to review age demographics for a specific setting. This affects the

design and planning considerations for hospital development.

1.2-2.2.4 Construction Type/Occupancy and Building Systems

1.2-2.2.4.1 New construction. If the proposed project is new construction that is not dependent on or

attached to an existing structure, the following shall be included:

(1) A description of construction type(s) for the proposed project



(2) A description of proposed occupancy(ies) and, if applicable, existing occupancy(ies)

1.2-2.2.4.2 Renovation. For a project that is a renovation of, or addition to, an existing building, the

following shall be included in the project narrative:

(1) A description of the existing construction type and construction type for any proposed renovations or

additions

(2) A general description of existing engineering systems serving the area of the building affected by the

proposed project

1.2-2.2.5 Project Components and Scope

1.2-2.2.5.1 The clinical and support areas affected by the project shall be identified.

1.2-2.2.5.2 The services required for the completed project to function as intended shall be described.

*1.2-2.2.6 Indirect Support Functions

Increased (or decreased) demands, workloads, staffing requirements, etc., imposed on support functions

affected by the project shall be described.

A1.2-2.2.6 Indirect support functions. These functions may or may not reside

adjacent to or in the same building or facility with the project.

*1.2-2.2.7 Operational Requirements

The operational requirements, which include but are not limited to the following, shall be described:

A1.2-2.2.7 Operational requirements. Project planning and design should

accommodate the governing body’s operational needs and objectives

commensurate with the scope and purpose of the project.

1.2-2.2.7.1 Projected operational use for project components

1.2-2.2.7.2 Relevant operational circulation patterns, including movement of staff, patients and their

companions, members of the public, and delivery and disposal of products, materials, and equipment

1.2-2.2.7.3 Departmental operational relationships and required adjacencies

*1.2-3 Space Program

*1.2-3.1 General. A space program shall be provided that contains a list organized by department or

other functional unit that shows each room in the proposed project, indicating its size by gross floor area.

and

A1.2-3.1 Project gross floor area

a. Gross floor area for the project should be aggregated by department;

multiplying factors should be applied to reflect circulation and wall thicknesses

within the department or functional area. This result is referred to as department

gross square footage (DGSF).



b. DGSF for the project should be aggregated; multiplying factors should be

applied to reflect interdepartmental circulation patterns, exterior wall thicknesses,

engineering spaces, general storage spaces, vertical circulation, and any other

areas not included within the intra-department calculations. This result is referred

to as building gross square footage (BGSF) and reflects the overall size of the

project.

1.2-3.2 Clear Floor Area. The clear floor area and citing relevant paragraph number(s) from this

document. shall be provided for each space for which a minimum clear floor area is required in the

Guidelines.

1.2-3.3 Guidelines Citations. The relevant Guidelines section numbers indicating space requirements

shall be cited.

*1.2-4 Safety Risk Assessment (SRA)

A1.2-4 SRA. The safety risk assessment is an interdisciplinary, documented

assessment process used to proactively identify hazards and risks and mitigate

underlying conditions of the built environment that may contribute to adverse

safety events. These adverse events include infections, falls, medication errors,

immobility-related outcomes, security breaches, and musculoskeletal or other

injuries. The SRA process includes evaluation of the population at risk and the

nature and scope of the project; it also takes into account the models of care,

operational plans, sustainable design elements, and performance improvement

initiatives of the health care organization. The SRA proposes built environment

solutions to mitigate identified risks and hazards.

*1.2-4.1 General

A1.2-4.1 Tools and information to assist in the development of a safety risk

assessment can be found on the websites of the Facility Guidelines Institute and

the Center for Health Design.

1.2-4.1.1 SRA Requirement

1.2-4.1.1.1 All hospital projects shall be designed and constructed to facilitate the safe delivery of care.

1.2-4.1.1.2 To support this goal, a multidisciplinary team shall develop a safety risk assessment.

1.2-4.1.2 SRA Components

See Table 1.2-1 (Safety Risk Assessment Components) to determine if the following SRA components

are required for a project:

1.2-4.1.2.1 Infection control risk assessment (ICRA)

1.2-4.1.2.2 Patient handling and mobility assessment (PHAMA)

1.2-4.1.2.3 Fall prevention assessment

1.2-4.1.2.4 Medication safety assessment



1.2-4.1.2.5 Behavioral and mental health risk assessment

1.2-4.1.2.6 Patient immobility assessment

1.2-4.1.2.7 Security risk assessment

1.2-4.1.2.8 Acoustics and noise risk assessment

1.2-4.1.3 SRA Responsibility and Scope

The safety risk assessment shall:

1.2-4.1.3.1 Be initiated and managed by the governing body during the planning phase of the project.

1.2-4.1.3.2 Evolve with additional levels of detail as needed to support the creation of a safe environment

throughout the design, construction, and commissioning phases of a project.

*1.2-4.1.4 SRA Team

The governing body of the health care organization shall appoint a multidisciplinary team to conduct the

safety risk assessment.

A1.2-4.1.4 SRA team members and roles. The SRA team should coordinate all

safety considerations and consolidate overlapping recommendations. See

appendix table A1.2-a (Safety Risk Assessment Team Member Expertise) for a

list of potential team members by SRA component type.

1.2-4.1.4.1 Members of the SRA team shall be convened as a group as needed to maintain continuity and

integration of the SRA components.

1.2-4.1.4.2 Individual members shall be engaged to develop additional detail according to their areas of

expertise.

*1.2-4.1.5 SRA Process

A1.2-4.1.5 SRA tools and methods. A range of high-priority activities to

improve patient and caregiver safety outcomes should be considered during the

predesign, design, and construction phases of a project.

1.2-4.1.5.1 Identify hazards and potential risks. The governing body shall provide an assessment of the

potential harm to patients, caregivers, and other users for the risks listed in Table 1.2-1 (Safety Risk

Assessment Components), identifying the following:

*(1) Hazards specific to the project

A1.2-4.1.5.1 (1) Hazards include physical obstacles and underlying conditions

that may directly or indirectly contribute to harm to patients, staff, or other users.

See appendix section A1.2-4.1.5.2 (Evaluation of underlying conditions that can

cause adverse safety events) for more information.

(2) Historical data and/or national patient and caregiver safety trends relevant to the identified hazards

(3) Prioritization of the degree of potential harm to patients and/or caregivers from the identified hazards

*1.2-4.1.5.2 Evaluate hazards and risks. The SRA team shall evaluate underlying conditions that



contribute to an unsafe environment for the components listed in Table 1.2-1 (Safety Risk Assessment

Components).

A1.2-4.1.5.2 Evaluation of underlying conditions that can cause adverse

safety events

a. Underlying conditions include the physical environment, organizational and

social factors, and task characteristics that can be affected by the design of a

space, including the following:

—Noise

—Vibration

—Visual distraction and disorganization of space

—Light type, quality, and quantity for each location

—Surface characteristics for different spaces

—Indoor air characteristics for different spaces

—Sources of infection

—Ergonomics

—Staff fatigue

—Space required to accommodate functions

—Standardized locations for equipment (e.g., medical gas outlets on patient

room headwalls, emergency call buttons)

—Opportunities for, and barriers or disincentives to, mobilization of patients

—Impediments to movement, maneuvering, and flow

—Communication systems

⎯Power source, branch of power, availability, and reliability

—Visibility of patients

—Automation (where possible)

—Support for family involvement in patient care

b. Ligature-resistant design provisions should be considered in areas such as

patient rooms, toilet rooms (e.g., patient, family, public), and treatment areas,

regardless of whether the area exclusively serves behavioral and mental health

patients.

c. For additional information, see the Center for Health Design report,

“Designing for Patient Safety: Developing Methods to Integrate Patient Safety

Concerns in the Design Process,” which identifies 10 environmental factors as



“latent conditions that can be designed to help eliminate harm.” Such “built

environment latent conditions [holes and weaknesses] that adversely impact

patient safety” should be identified and eliminated during the planning, design,

and construction of a hospital. The report can be found on the Center for Health

Design website.

*1.2-4.1.6 SRA Report

After completing the SRA process, the governing body shall provide the following information and

recommendations, which shall be incorporated into the planning and design documentation:

A1.2-4.1.6 SRA report. Time and effort should be dedicated to patient and

caregiver safety issues during the predesign phase (e.g., strategic planning,

master planning, operational planning, and programming) of a hospital design

project. The decisions made during predesign significantly affect the design

parameters going forward and the safety outcomes of the project following

occupancy. The safety risk assessment should be an important part of the

continuous safety improvement program in any health care organization.

1.2-4.1.6.1 Patient and caregiver safety hazards and risks identified by the safety risk assessment. See

Section 1.2-4.1.5.1 (Identify hazards and potential risks).

1.2-4.1.6.2 Design features that contribute to the identified hazards and risks

1.2-4.1.6.3 Design strategies to reduce, mitigate, or eliminate identified hazards and risks

1.2-4.1.7 SRA Compliance

1.2-4.1.7.1 SRA documentation

(1) Written records shall remain an active part of the project documents for the duration of design,

construction, and commissioning.

(2) The records shall include the SRA recommendations report and any documentation completed as part

of the SRA process.

1.2-4.1.7.2 SRA communication

(1) The SRA team shall provide updates to the planners and designers for compliance with additional

levels of detail generated during the project for all safety components listed in Table 1.2-1 (Safety

Risk Assessment Components).

(2) Changes to the original design plans shall be documented, updated, and continually shared between

the SRA team and the designers, planners, governing body, and contractor.

*1.2-4.2 Infection Control Risk Assessment (ICRA)

A1.2-4.2 ICRA. The ICRA is a documented process to proactively:

a. Identify and plan safe design elements, including consideration of long-range

infection prevention.

b. Identify and plan for internal and external building areas and sites that will be

affected during construction/renovation.



c. Identify potential risk of transmission of airborne and waterborne biological

contaminants during construction and/or renovation and commissioning.

d. Develop infection control risk mitigation recommendations (ICRMRs) to be

considered.

1.2-4.2.1 General

1.2-4.2.1.1 ICRA requirement. For a hospital project to support safe designs, HVAC/plumbing systems,

and surface and furnishing material selections, an ICRA shall be a part of integrated facility planning,

design, construction, and commissioning activities and shall be incorporated into the safety risk

assessment.

1.2-4.2.1.2 ICRA recommendations. Based on the results of the initial stage of the ICRA, the governing

body shall provide the following recommendations for incorporation into the safety risk assessment:

(1) Design recommendations generated by the ICRA

(2) Infection control risk mitigation recommendations (ICRMRs) for construction and commissioning.

See Section 1.2-4.2.3.1 (Infection control risk mitigation recommendations).

1.2-4.2.2 ICRA Considerations

At minimum, the ICRA shall address the following:

1.2-4.2.2.1 Design elements. See Table 1.2-2 (Infection Control Risk Assessment Design Considerations)

for cross-references to more information.

(1) Airborne infection isolation (AII) and protective environment (PE) rooms

(a) The number, location, and type of airborne infection isolation (AII), and protective environment

(PE) rooms, and combination airborne infection isolation/protective environment (AII/PE) rooms)

shall be determined by the ICRA with minimum numbers as where these rooms are required in the

facility type chapters in the Guidelines.

*(b) Whether an anteroom is ot be provided for each AII room shall be determined by the ICRA.

A1.2-4.2.2.1 (1)(b) Anteroom considerations

a. The following elements should be considered when determining whether an

anteroom will be provided:

—Location and intended use of the AII room

—Facility location (e.g., a densely populated city or a city with an international

airport), addressing the likelihood of receiving a patient with a known

airborne transmissible disease or an emerging infectious disease with

unknown transmission patterns

—Long-range infection prevention planning (e.g., pandemic response)

b. The purpose of an anteroom for an AII room is to provide:

—A buffer zone between the isolation room and the corridor to contain potential

infectious particle escape due to transient airflow across the open doorway



—Space for storage and disposal of personal protective equipment (PPE)

—Space for staff to safely don and doff PPE that is separated from the general

unit traffic

*(2) The ICRA shall address special heating, ventilation, and air-conditioning (HVAC) needs required to

accommodate the services (e.g., surgical suites, AII/PE rooms, laboratories, pharmacies, areas with

local exhaust systems for hazardous agents, and other special areas) performed in spaces included in or

affected by the project.

A1.2-4.2.2.1 (2) Airborne contamination can result when HVAC systems are

improperly designed, built, or maintained. In addition to providing comfort and

minimizing exposure to chemical pollution, ventilation systems are an important

means for preventing infection. An HVAC system expert, whether an

independent engineer or an employee of the governing body, should determine

which of the following HVAC design considerations should be covered in the

ICRA:

a. Characteristics of overall HVAC system design as well as design for specific

sensitive areas, including components, capacity, filtration, air changes, pressure

relationships, and directional flow

b. Ease of access for HVAC system maintenance

c. Ease of general maintenance activities and system cleaning

d. Selection of air distribution devices that allow for minimal or easy cleaning

e. Location of air intakes and exhaust outlets to prevent cross-contamination

f. Redundancy in equipment and systems

g. Plan for HVAC system outages and maintenance (both planned and

unplanned)

(3) Water/plumbing systems

(a) The minimum number, location, and type of plumbed hand-washing stations, hand sanitation

dispensers, and emergency first-aid equipment (e.g., eyewash stations and deluge showers) are

identified in the facility chapters in the Guidelines. The need for additional fixtures shall be

addressed in the ICRA.

*(b) The ICRA shall include an assessment of the risk from transmissible waterborne, opportunistic

pathogens and establish strategies to mitigate the risk.

A1.2-4.2.2.1 (3)(b) See ANSI/ASHRAE Standard 188: Legionellosis: Risk

Management for Building Water Systems for implementation of water

management programs which may impact the design, construction, and

commissioning of building water systems during renovation, additions, or

modifications to an existing building, or prior to the occupancy of a newly

constructed building.

*(4) Characteristics related to infection prevention for selection of materials for surfaces and furnishings



A1.2-4.2.2.1 (4) See appendix sections A2.1-7.2.3 (Characteristics and criteria

for selecting surface and furnishing materials and products) and A2.1-7.2.4 (a)

(Characteristics and criteria for selecting furnishing materials and products) for

information on characteristics and criteria for selecting surface and furnishing

materials for hospitals.

1.2-4.2.2.2 Construction elements. When conducting the ICRA and developing infection control risk

mitigation recommendations (see Section 1.2-4.2.3) for building and site areas anticipated to be affected

by construction, the following shall be addressed:

*(1) The impact of disrupting essential services to patients and employees

A1.2-4.2.2.2 (1) Hazards specific to different types of essential service

disruptions should be proactively determined. A plan should be developed to

ensure continued provision of service in the event of both planned and unplanned

disruptions.

(2) The specific hazards and protection levels for each designated area

(3) Location of patients according to their susceptibility to infection and the definition of risks to each

(4) The impact of movement of debris, traffic flow, spill cleanup, and testing and certification of installed

systems

(5) Assessment of external as well as internal construction activities

(6) Location of known hazards

1.2-4.2.3 Infection Control Risk Mitigation

*1.2-4.2.3.1 Infection control risk mitigation recommendations (ICRMRs). These written plans shall

describe the specific methods by which transmission of airborne and waterborne biological contaminants will

be avoided during construction as well as during commissioning, when HVAC and plumbing systems and

equipment (e.g., ice machines, steam sterilization systems) are started/restarted.

A1.2-4.2.3.1 Responsibilities for performing risk mitigation procedures should be

included in infection control risk mitigation plans to assure proper actions are

taken at the appropriate time.

1.2-4.2.3.2 ICRMR planning. ICRMRs shall be prepared by the ICRA team.

1.2-4.2.3.3 ICRMR content. ICRMRs shall, at minimum, indicate how the following issues will be

addressed during construction:

(1) Patient proximity to construction activities and potential need for patient relocation

*(2) Standards for barriers and other protective measures required to protect adjacent areas and susceptible

patients from airborne contaminants

A1.2-4.2.3.3 (2) Ventilation of the construction zone

a. Airflow into the construction zone from occupied spaces should be maintained

by means of a dedicated ventilation/exhaust system for the construction area.



b. Locations of exhaust discharge relative to existing fresh air intakes and filters,

as well as the disconnection and sealing of existing air ducts, should be reviewed

as required by the ICRA.

c. If the existing building system or a portion thereof is used to achieve this

requirement, the system should be thoroughly cleaned prior to occupancy of the

construction area.

d. Hospital construction barriers for projects in high-risk areas should be

maintained at a pressure differential of at least 0.03-inch water gauge (7.0

Pascals), with airflow from hospital clean areas to construction dirty areas.

Construction barriers in high-risk areas should have visual display of airflow

direction. (High-risk areas include critical care units; emergency departments;

labor and delivery facilities, including cesarean delivery rooms; newborn

nurseries; areas serving pediatric patients; pharmacies; surgical units; post-

anesthetic care units; areas serving immunocompromised patients; burn units;

sterile processing; airborne infection isolation rooms and protective environment

rooms; oncology units; Class 2 and Class 3 imaging rooms; and operating

rooms.)

(3) Temporary provisions or phasing for construction or modification of HVAC and water supply systems

(4) Protection from demolition

(5) Training for staff, visitors, and construction personnel

*(6) The impact of potential utility outages or emergencies, including the need to protect patients during

planned and unplanned utility outages and evacuation

A1.2-4.2.3.3 (6) Disaster plans for water supply and ventilation emergencies

a. The governing body should provide a written plan for what will happen in the

event of a water outage. This should include location of supplies, who is

responsible for what, and who is to be notified.

b. The governing body should provide a written plan for what will happen in the

event of an air shutdown. This should include who is responsible for what and

who is to be notified.

c. The governing body should provide a written plan for what will happen in the

event of a water leak. This should include who is to be notified.

(7) The impact of movement of debris, traffic flow, cleanup, elevator use for construction materials and

construction workers, and construction worker routes

(8) Provision for use of bathroom and food facilities by construction workers

*(9) Installation of clean materials (particularly ductwork, drywall, and wood/paper/fabric materials) that

have not been damaged by water

A1.2-4.2.3.3 (9) Protection of building materials

a. Construction materials should be kept clean and dry, as appropriate.



b. Ductwork should be kept capped/clean during demolition and dust-generating

construction.

c. Drywall installation should not proceed until exterior protection against rain

damage has been installed.

*1.2-4.2.3.4 Monitoring plan and procedures

A1.2-4.2.3.4 Monitoring efforts should be determined by the governing body and

may be conducted by the governing body’s infection preventionists,

epidemiologists, construction coordinators, and/or safety staff or by independent

outside consultants.

(1) The governing body shall provide monitoring plans for effective application of ICRMRs during the

course of the project.

(2) Provisions for monitoring shall include:

(a) Written procedures for emergency suspension of work

(b) Protective measures indicating the responsibilities and limitations of each party (i.e., governing body,

designer, contractor, and monitor)

*1.2-4.3 Patient Handling and Mobility Assessment (PHAMA)

A1.2-4.3 PHAMA. A patient handling and mobility assessment is an

interdisciplinary, documented assessment process conducted to direct/assist the

design team in incorporating appropriate patient handling and mobility

equipment into the health care environment. The purpose of this equipment is to

increase or maintain patient mobility, independent functioning, and strength as

well as to provide a safe environment for staff and patients during performance

of high-risk patient handling tasks. See Section 1.2-4.7 (Patient Immobility

Assessment) for more details on the impact of equipment on patient mobility.

a. The PHAMA has two distinct, yet interdependent, phases:

—Phase 1: A patient handling and mobility assessment is performed to identify

appropriate patient handling and mobility equipment for each patient care area.

—Phase 2: The space, structural, and other design requirements needed to

accommodate patient handling and mobility equipment and to facilitate patients’

weight-bearing and physical activity are determined.

b. Information and guidance for conducting a PHAMA can be found in the FGI

Beyond Fundamentals library in a white paper titled “Patient Handling and

Mobility Assessments, 2nd ed.,” posted at www.fgiguidelines.org. The white

paper explains the rationale for considering patient handling equipment during

the design and construction process, information (including illustrations) about

various types of patient handling equipment, the business case for implementing

patient handling and mobility programs, and strategies for implementing such

programs.

c. Caregivers repositioning and transferring patients cannot lift more than 35

pounds manually without putting themselves at risk for back injuries. As a



consequence, caregivers are one of the groups at highest risk for injury of any

industry, and manual patient handling and moving are the primary causes. If

caregivers are not equipped to perform these necessary physical tasks safely,

patients may not receive adequate care and may remain inappropriately

immobile. Increasing evidence shows that early and frequent patient

mobilization is vital to the health of patients and is integral to quality care. See

Section 1.2-4.7 (Patient Immobility Assessment) for more details about

immobility prevention.

Equipment is now available to facilitate necessary clinical work while

significantly reducing the risk of caregiver and patient injury from patient

handling, moving, transfer, transport, and mobilization activities. Equipment is

also available to provide a viable support alternative to bedstay; see appendix

sections A1.2-4.3.2.2 (8) (Storage for patient handling and mobility equipment

and accessories) and A2.1-2.2.2 (Space considerations for patient mobility) for

more details about accommodations needed for equipment used to improve

patient mobility. By better supporting appropriate levels of care and reducing

risk of injury to caregivers, use of such equipment and related architectural

accommodations will improve outcomes and reduce the overall cost of care.

d. The following definitions apply to text in Section 1.2-4.3 (Patient Handling

and Mobility Assessment):

—Whenever the term “equipment” is used, it refers to patient handling and

mobility equipment.

—“Fixed” equipment refers to equipment with track systems attached at some

point within the room. Fixed equipment includes overhead (ceiling-mounted

or wall-mounted) lifts and other lifting devices with fixed tracking. An

alternative would be a demountable track that may be fully or partially

disassembled and removed from the space.

—“Portable” or “mobile” equipment is floor-based equipment that moves on the

floor surface, such as floor-based sling lifts and sit-to-stand lifts. These may be

moved horizontally manually or with the assistance of motorized wheels.

When the term “portable” is used in connection with ceiling lifts, it may also

refer to a lift motor and hoist that can be removed from the track system in one

room and attached to the track system in another room.

1.2-4.3.1 General

1.2-4.3.1.1 PHAMA requirement

*(1) The governing body of the hospital shall provide the project design team with a PHAMA that

addresses the specific patient handling and mobility needs of all areas affected by a project.

A1.2-4.3.1.1 (1) PHAMA team. In addition to those listed in appendix table

A1.2-a (Safety Risk Assessment Team Member Expertise), the unit/area nurse

manager/supervisor, physical therapy/rehabilitation staff, and those with

expertise in risk management should contribute their expertise related to patient

handling and mobility to development of the PHAMA. In cases in which the

patient population may present specific risks (e.g., a higher-than-normal

individual of size population), the design team may seek guidance from an expert



(e.g., an ergonomist) to facilitate development of solutions during the

preliminary phase of a project.

(2) The governing body shall incorporate the findings and recommendations of the PHAMA into the

safety risk assessment.

1.2-4.3.1.2 Design recommendations

*(1) PHAMA results and recommendations shall be specific to each patient care area where patient

handling and mobilization occur.

A1.2-4.3.1.2 (1) Areas to be included in PHAMA design recommendations.

Examples of areas to be covered in the PHAMA include clinical units, along with

associated toileting, bathing, and showering areas; procedure areas; diagnostic

areas; pre- and post-procedure patient care areas; the morgue; ambulance bays;

dining and recreation areas; and the routes connecting them. Because different

areas serve patient populations with varying characteristics, equipment

recommendations will also vary. For this reason, recommendations should be

developed for each unit or other area that is part of a new construction or

renovation project. The objective is to assure that equipment of the correct type,

size, weight capacity, and quantity is available in each area and that sufficient

storage is allocated for this equipment.

(2) The findings and recommendations of the PHAMA shall include consideration of the patient care

requirements for all patients, including individuals of size.

1.2-4.3.2 Patient Handling and Mobility Elements for the Safety Risk Assessment

1.2-4.3.2.1 Phase 1: Patient handling and mobility assessment. Evaluation of patient handling and

mobility needs shall include at minimum the following considerations:

*(1) Patient handling and mobility equipment recommendations, based on the following:

A1.2-4.3.2.1 (1) Patient handling and mobility equipment

recommendations

a. In addition to the factors listed in the main text, recommendations for

patient handling and mobility equipment are also based on the following:

—Patient dependency levels. This information is critical in determining patient

handling and mobility needs. To simplify determination of dependency levels,

patients are usually grouped into categories based on physical limitations (not

clinical acuity). Recommended categories include total dependence/extensive

assistance, partial assistance, and independent.

—Consideration of the weight and size of individuals of size. This is important to

assure equipment with appropriate capacities is provided.

—Patient handling and mobility tasks for which equipment is used to minimize

risk. These should include the following:

• Vertical and lateral transfers (from/to a bed, stretcher, gurney, chair,

commode, toilet, or wheelchair)



• Positioning/repositioning in bed (side to side, up to the head of the bed,

raise or lower head or feet)

• Repositioning in chair

• Showering/bathing

• Lifting appendages

• Transporting patients

• Assisting patient ambulation

• Weighing patients on bed scales

b. To correctly identify all high-risk patient handling tasks and impediments or

hindrances to patient mobility on a unit or in an area, analyze unit injuries for

common task involvement, conduct walkthroughs, and interview and/or survey

front-line staff (e.g., nursing, rehab, therapists) for their perceptions of high-risk

tasks.

c. Many types of patient handling and mobility equipment are available, but

only those that affect building design need be considered in a PHAMA. New

equipment designs will need to be evaluated for building design impact as

they become available. Presently, equipment that significantly influences

design includes, but is not limited to, bathing/shower chairs,

beds/stretchers/trolleys/gurneys, wheelchairs, and lateral transfer devices.

Fixed patient lifts (i.e., ceiling- and wall-mounted lifts) and portable patient

lifts (e.g., sit-to-stand lifts and floor-based sling lifts) are further described

below, as their design impact may be significant. Other transfer devices and

accessories in addition to those mentioned above (e.g., slings, transfer sheets

and boards, and trapezes) influence design to the extent that storage is

required.

—Sit-to-stand lifts are used to assist a patient who requires partial assistance and

who possesses some weight-bearing ability. Sit-to-stand lifts assist in vertical

transfers, toileting, dressing, peri-care, and ambulation.

—Floor-based sling lifts and ceiling-mounted lifts are used for patients who are

completely or substantially unable to assist caregivers. Patients requiring these

levels of care are often described as “dependent” or requiring “extensive

assistance.” The utility of these lifts for this population includes but is not

limited to vertical transfers, lateral transfers, repositioning in bed and chair,

lifting appendages, and lifting patients from the floor. These lifts also can be

used for assistance with ambulation rehabilitation or mobilization of patients

with some weight-bearing capability.

*(a) Characteristics of projected patient populations

A1.2-4.3.2.1 (1)(a) See appendix section A2.1-2.2.2 (Space considerations for

patient mobility) for information about patient mobility considerations.

(b) Types of high-risk patient handling and mobility tasks to be performed



(c) Knowledge of specific technology to enable physical activity by patients and reduce risk for each

patient handling and mobility task

(d) Architectural factors that interfere with use of patient handling equipment or impede mobility

*(2) Types of patient handling and mobility equipment to be used (e.g., manual or power-assisted fixed

ceiling or wall-mounted lifts, manual or power-assisted floor-based sling or sit-to-stand lifts, electric

height-adjustable beds, or a combination thereof)

A1.2-4.3.2.1 (2) Equipment that will be used. Patient care providers who are

familiar with the characteristics of their unique patient populations should be

included in the design and equipment selection process to assure appropriate

equipment decisions are made.

When conducting an equipment needs assessment, any existing equipment that

will be used on the unit should be considered. For each area included in the

PHAMA, use a log to collect information on existing equipment, the percentage

of time it is used and—if this is not 100 percent—reasons for the percentage of

time indicated.

*(3) Quantity of each type of patient handling and mobility equipment needed for each area

A1.2-4.3.2.1 (3) The dependency level of the patients should determine the

quantity of lifts required.

a. The average percentage of “dependent/extensive assistance” patients should be

used to determine the number and placement of fixed lift systems and/or the

quantity of floor-based sling lifts.

b. When only floor-based lifts are used, one lift per 8 to 10 patients is a typical

planning ratio. When fixed lift systems are used, the location and configuration

of track systems will determine potential coverage options. For example, if 70

percent of patients are dependent or require extensive assistance and there are 30

patients on the unit, fixed lift coverage will be needed for 21 patients (70 percent

of 30). If the patient rooms are private, 21 rooms will need fixed lifts. If the

patient rooms are semi-private, 10 to 11 rooms will need fixed lifts.

c. Installation of fixed lift systems will reduce, but not entirely eliminate, the

need for floor-based lifts since most fixed lift systems do not provide complete

coverage of patient use areas.

d. The number of patients who need partial assistance should be used to

determine the number of sit-to-stand lifts needed. A similar ratio of one lift per 8

to 10 patients may be used.

e. Peak patient handling times may increase the quantity of lifts required.

*(4) Required weight-carrying capacities

A1.2-4.3.2.1 (4) Lift weight capacities range from approximately 400 pounds

(181 kilograms) to expanded-capacity lifts of 1,000 pounds (454 kilograms) or

more. Specification of lifts with a capacity of 500–600 pounds (227–272

kilograms) will accommodate the greatest range of all patients. The lifts



designated for use by individuals of size should support the projected weight of

individuals of size identified during the planning phase. See Section 1.2-6.4.1

(Projected Need for Accommodations for Care of Individuals of Size).

*(5) Locations/rooms/areas where patient handling, movement, and mobility equipment will be used, with

installation requirements (if fixed) and storage requirements

A1.2-4.3.2.1 (5) Nursing unit staff will be the best resource for determining

which rooms on a unit should have fixed lift installations and storage locations

for portable lifts.

A patient care ergonomic (PCE) evaluation is an important step in determining

the patient handling technology required to implement a “minimal lift” policy.

It is highly recommended that health care organizations conduct a thorough

PCE evaluation, which will provide recommendations for other patient

handling and mobility technology as well as programmatic issues related to

safe patient handling and mobility. Information about how to conduct a PCE

evaluation can be found in “Patient Handling and Mobility Assessments, 2nd

ed.” posted at www.fgiguidelines.org.

1.2-4.3.2.2 Phase 2: Design considerations. The impact of patient handling and mobility needs on

building design shall be addressed in the PHAMA, including consideration of the patient care needs of all

patients, including individuals of size. These design considerations shall incorporate results from the

Phase 1 assessment and shall include, at minimum, the following:

(1) Structural considerations to accommodate current and/or future use of fixed equipment that supports

patient handling and mobility

*(2) Electrical and mechanical considerations for current and future use and/or installation of patient

handling and mobility equipment and associated storage and charging areas

A1.2-4.3.2.2 (2) Electrical and mechanical considerations

a. For portable lifts. Battery-charging areas with electrical services should be

provided in storage rooms for portable, floor-based lifts and other assistive

devices.

b. For fixed lifts. Access to both electrical power and emergency control features

(often suspended from the motor housing) should be provided for fixed lifts.

*(3) Adequate space for provision of patient care and for unhindered maneuvering of patient

handling and mobility equipment. For clearance requirements to accommodate individuals of

size, see Section 2.1-2.3.2 (Accommodations for Care of Individuals of Size—Patient Room).

A1.2-4.3.2.2 (3) Space for use of patient handling and mobility equipment.

See appendix section A2.1-2.2.2 (Space considerations for patient mobility) for

mobility clearance suggestions.

*(4) Destination points for patient ambulation, transfers, and transport

A1.2-4.3.2.2 (4) Consider various destinations for patient transport using patient

handling and mobility equipment (i.e., locations to and from which patient

mobilization is to be accomplished, such as within the patient room—bed, chair,

http://www.fgiguidelines.org/



commode, etc.—and into the associated toilet room). Also consider patient

destinations to foster patient ambulation and mobility such as a meditation room

or therapeutic garden. Such considerations will aid in selecting appropriate

equipment and designing the room and door openings to accommodate portable

equipment and related track systems and the patients and caregivers using it.

*(5) Sizes and types of door openings through which patient handling and mobility equipment and

accompanying staff must pass. See Section 2.1-2.3.10.2 (Special Design Elements for Spaces for Care

of Individuals of Size—Door openings) for additional requirements.

A1.2-4.3.2.2 (5) See appendix section A2.1-7.2.2.3 (2) (Door openings—general)

for more information about door openings and patient mobility.

*(6) Types of floor surfaces and transitions needed to facilitate safe and effective use of patient handling

and mobility equipment

A1.2-4.3.2.2 (6) Types of floor surfaces and transitions. See Section 2.1-

7.2.3.1 (Flooring and wall bases) and its appendix for more information.

(7) Coordination of patient handling and mobility equipment installations with building mechanical,

electrical, communication, and life safety systems

*(8) Storage space requirements and locations available or to be provided

A1.2-4.3.2.2 (8) Storage for patient handling and mobility equipment and

accessories

a. Accessibility of patient handling equipment is critical to assuring it will be

used. Storage needed for the type and quantity of equipment identified during the

project planning phase should be incorporated during project design.

b. Storage will be needed for patient handling equipment accessories such as lift

slings, hanger bars, and trapezes as well as for other patient handling equipment.

Operational considerations when determining storage space requirements

include:

—Surplus slings should be stored in the same location as portable lifts.

—In storage areas, large hooks should be installed for hanging slings or shelving

should be provided for storage of folded slings.

—Slings assigned to a specific patient should be stored in the patient room (e.g.,

on a hook on the outside of the patient’s closet, at the bedside, or somewhere

near the entry door) to provide instant accessibility and ensure compliance.

—Standard shelving should be provided for storage of an assortment of slings for

lifts, extra lift hanger bars, and other patient handling equipment, such as

friction-reducing devices and air-assisted lateral transfer aids with motor(s).

—Storage alternatives: For small units, a centrally located storage area may be

provided. For large or small units, storage may be provided in alcoves or

storage areas interspersed throughout the unit.

(9) Impact of the installation and use of patient handling and mobility equipment on environmental



characteristics of the environment of care

*(10) Impact of the installation and use of patient handling and mobility equipment on the aesthetics of

the patient care space

A1.2-4.3.2.2 (10) When installing fixed-lift systems, care should be taken to

minimize the visual impact of fixed tracks, slings, hanger bars, and motors on the

aesthetics of the physical environment. Use of recessed tracks is suggested as

well as curving the track away from the center of the patient room. Other

suggestions include enclosing lift motors in decorative cabinets and concealing or

masking wall-mounted rails for traveling gantry lifts with crown molding or

indirect ceiling light coves.

*(11) Infection control recommendations

A1.2-4.3.2.2 (11) For effective infection control, consult with an infection

preventionist during development of and while conducting the PHAMA.

Incorporate the facility’s infection control guidelines and manufacturer’s

cleaning instructions into planning. Use of lifts in certain areas, such as a surgical

suite, may have more stringent requirements.

*1.2-4.4 Fall Prevention Assessment

A1.2-4.4 Fall prevention risk assessment. Consideration for fall prevention and

mitigation includes evaluation of the patient population at risk and the design

features to mitigate fall and injury risk based on the nature and scope of the

project. The SRA team (see Section 1.2-4.1.4) should proactively identify and

plan design elements to help prevent falls and mitigate injuries associated with

falls.

*1.2-4.4.1 Fall Prevention Elements of the Safety Risk Assessment

A1.2-4.4.1 Patient fall prevention program. A comprehensive fall prevention

program includes many elements beyond those found in the physical

environment. The U.S. Department of Veterans Affairs (VA) National Center for

Patient Safety is an authoritative source for information, guidance, references,

and algorithms to assist with patient fall prevention, including a Falls Toolkit. In

addition, the Business and Institutional Furniture Manufacturers Association

(BIFMA) is an industry source for standards related to furniture.

1.2-4.4.1.1 Fall-risk locations. The SRA report shall identify fall-risk locations for a new construction or

renovation project.

*1.2-4.4.1.2 Design features. The SRA team shall identify required patient fall prevention design features

for the identified at-risk locations. See Section 2.1-7 (Common Elements for Hospitals—Design and

Construction Requirements).

A1.2-4.4.1.2 Design features. Evidence for the identification of single

environmental variables and their importance in patient falls is still emerging.

However, a number of studies that examined multiple variables suggest an

association between falls and the environmental variables listed here. Additional

detail can be found in the Center for Health Design paper “Contribution of the

Designed Environment to Fall Risk in Hospitals.”



a. Patient room features

—Family zones in patient rooms. Patient rooms with space for family zones have

been shown to contribute to fewer patient falls.

—Space on the opening side of the patient toilet room door. Provision of an 18-

inch (45.72-centimeter) space on the opening side of the patient toilet room

door makes it possible to open the door without stepping backward; this

arrangement has been shown to facilitate movement of patients using IV poles,

walkers, and other assistive devices.

—Handrails on walls leading to the patient toilet room

—Provision of patient-adjustable lighting, including night-lighting

—Elimination of room clutter that narrows the path for safe patient movement

—Elimination of trip hazards such as ottomans and furniture legs

b. Ceiling-mounted lift considerations

—Provision of lifts leading from the patient bed into the patient toilet room

—Provision of lifts in the patient unit corridor to assist with ambulation

c. Patient toilet room considerations

—Location of the patient toilet room by the headwall rather than across the room

—Provision of a private toilet room accessed by only one patient

—Toilet location in the patient toilet room

—Location and number of toilet grab bars

d. Flooring. See Section 2.1-7.2.3.1 (Flooring and wall bases) for information.

e. Noise attenuation. Noise has been found to contribute to falls, especially noise

generated from overhead paging and alarms. Consideration should be given to

selecting equipment for noise control. For more information, see appendix

section A1.2-4.9 (Acoustics and Noise Safety Risk Assessment).

f. Location of nurse station. Decentralized nurse stations may increase the

opportunity to view and assist patients.

g. Furniture. See Section 2.1-7.2.4.1 (Built-in furnishings) for information.

h. Equipment. See appendix section A1.2-4.3 (Patient Handling and Mobility

Assessment) for a description of equipment to support patient handling and

mobilization and reduce the risk of patient falls.

i. Technology (e.g., bed alarms)

1.2-4.4.2 Fall Prevention Response



1.2-4.4.2.1 The design team shall incorporate required patient fall prevention design features in the

project design documents.

1.2-4.4.2.2 For renovation projects, documentation shall describe the specific fall risk mitigation methods

to be used in and around construction zones and shall, at minimum, address the following:

(1) Standards for barriers and other protective measures required to protect adjacent areas and susceptible

patients from clutter and construction dust on flooring

(2) Protection from demolition debris on flooring

*1.2-4.5 Medication Safety Assessment

A1.2-4.5 Medication safety should be evaluated and documented by the SRA

team so that design can support improved medication safety by identification of

medication safety zones and development of design features to mitigate risk

based on the nature and scope of the project.

*1.2-4.5.1 Medication Safety Elements of the Safety Risk Assessment

A1.2-4.5.1 Medication safety elements. Many technologies have been

developed to help reduce medication errors. These include pharmacy order

review software for validating orders, technologies such as robotics and unit dose

dispensing equipment that improve accuracy of medication dispensing, and

delivery technologies such as QR codes and bar coding. Physical environment

supports for these and other relevant technologies should be considered as part of

a comprehensive approach to reduction of medication errors and adverse drug

events.

1.2-4.5.1.1 Number and location of medication safety zones. The governing body shall identify the

number and location of medication safety zones for the project and include them in the SRA report.

1.2-4.5.1.2 Design features. Medication safety zones shall meet the requirements in Section 2.1-2.8.8

(Medication Safety Zones).

1.2-4.5.2 Medication Safety Response

The design team shall incorporate the required medication safety design features in the project design

documents.

*1.2-4.6 Behavioral and Mental Health Risk (Psychiatric Patient Injury and Suicide Prevention)

Assessment

A1.2-4.6 Behavioral and mental health risk assessment. Risk should be

determined through simultaneous consideration of the inherent danger of any

single environmental features because of throughout the facility based on patient

profile and acuity, and the potential for harm against self or others anticipated

level of staff supervision for each area, and patient visualization.

a. The governing body should develop a detailed assessment of the level of risk

for each program area in the facility where behavioral and mental health patients

may present, be diagnosed, or treated. Consideration should include patients with

comorbidities (i.e., a patient with both medical and behavioral and mental health

conditions) even if the primary diagnosis is a medical condition. where mental



health patients will be served (e.g., emergency department and nursing units).

See appendix table A1.2-a (Safety Risk Assessment Team Member Expertise) for

areas of expertise needed on the behavioral and mental health assessment team.

b. Each area should be evaluated to identify the architectural details, surfaces,

and furnishings and exposed mechanical and electrical devices and components

to be addressed in the risk assessment.

c. Consideration should take into account the relative risk of the space based on

patient acuity, whether the patient is alone or among other patients and staff, and

the specific spatial conditions created through the layout and configuration (e.g.,

visibility). Industry guidance documents suggest the following risk levels by

space type. Examples of areas to be included in a mental health risk assessment

include the following:

—High level: areas where patient acuity poses increased risk, areas where

patients are alone or under minimal supervision, and areas where the risk has

not yet been identified. Examples include:

• Seclusion rooms (where patient acuity poses an increased risk)

• Patient bedrooms

• Patient toilet rooms and bathing facilities and toilet rooms (areas where

patients spend long periods of time out of direct supervision of the staff)

• Psychiatric emergency Emergency department (comprehensive

psychiatric emergency program, or CPEP, an area under good supervision

but dealing with unpredictable patients under initial evaluation and often

under heavy medication)

• Intake/interview rooms (where unknown patient acuity poses an increased

risk)

—Moderate-high level: areas where patients interact with less direct supervision.

Examples include:

• Activity spaces, group rooms, and treatment spaces (supervised with good

visibility)

• Dining rooms areas and recreation spaces, both indoor and outdoor

• Quiet rooms

• Patient-use laundry rooms

—Moderate-low level: areas where patients are supervised and/or under direct

observation. Examples include:

• Procedure rooms, examination/treatment rooms, and specialty therapy

rooms (Note: exam/treatment rooms also may be considered higher risk

depending on understanding of patient acuity



• Counseling/consultation rooms

• Visitor rooms

• Corridors (always visible)

—Low level: public spaces and staff services areas where patients are not

allowed. Examples include:

• Public lobby area

• Waiting rooms (with direct supervision and observation of patients)

• Private offices

• Exam rooms, private offices, and conciliation rooms (always supervised)

• Locked S staff and support areas (not accessible by patients)

Other information that could be considered can be found in “Patient Safety

Standards, Materials and Systems Guidelines,” published by the New York State

Office of Mental Health, and the “Behavioral Health Design Guide,” published

by the Facility Guidelines InstituteBehavioral Health Facility Consulting, LLC.

1.2-4.6.1 Behavioral and Mental Health Elements of the Safety Risk Assessment

The SRA report shall identify areas where patients at risk of mental health injury and suicide will be

served.

1.2-4.6.2 Behavioral and Mental Health Response

1.2-4.6.2.1 The SRA team shall identify mitigating features for the identified at-risk locations.

1.2-4.6.2.2 The design of behavioral and mental health patient care settings shall address the need for a

safe treatment environment for those who may present unique challenges and risks as a result of their

behavioral and mental health condition.

(1) This patient environment shall be designed to protect the privacy, dignity, and health of patients and

address the potential risks related to patient elopement and harm to self, others, and the care

environment.

(2) The design of behavioral and mental health patient areas shall accommodate the need for clinical and

security resources.

*1.2-4.7 Patient Immobility Assessment

Patient immobility risk in patient care areas shall be assessed to identify design factors that discourage

patient mobility and determine how to mitigate their contribution to sedentary patient treatment and

behavior.

A1.2-4.7 Patient immobility risk assessment. The purpose of assessing risk for

patient immobility is to decrease the risk of hospital-acquired disabilities caused

by lack of mobility.



a. Patient immobility (a decrease in the time a patient spends out of bed and

moving) causes loss of muscle strength and harmful changes in the heart and

blood vessels as well as increasing chances of delirium, pressure ulcers, venous

thromboembolism, falls, and functional decline. Functional decline (the loss of

ability to perform activities that ensure independence, such as getting to the

toilet) leads to increased lengths of hospitalization and readmission.

b. Design of the hospital physical environment can influence whether a person

remains inappropriately immobile and can be used to encourage and enable

patients to remain active. It can also support rehabilitation and caregiver efforts

to keep patients mobile and . Design considerations for prevention of immobility


—Identification of patient care areas in the scope of the project that serve

inpatient populations at risk for immobility

—Identification of conditions that foster immobility or work together to keep

patients in bed

—Identification of furniture and equipment that supports weight-bearing patient

mobility and assessment of the space needed for its use and storage

—Specification of project environmental design features that facilitate patient

mobility

*1.2-4.8 Security Risk Assessment

A1.2-4.8 Security risk assessment. A security risk assessment addresses the

unique security characteristics of a hospital, including specific needs related to

the protection of vulnerable patient populations, the security of sensitive areas,

the application of security and safety systems, and the infrastructure required to

support these needs. The assessment addresses external and internal security

needs as well as security needs related to emergency management and response.

Security requirements for construction, commissioning, and move-in vary

according to the complexity and scope of services provided.

More detailed information regarding the guidelines in this section can be found in

Security Design Guidelines for Healthcare Facilities, published by the

International Association for Healthcare Security & Safety (IAHSS).

1.2-4.8.1 Project Security Plan

For new construction or renovation projects, a security plan shall be developed that addresses risks from

the environment, function of the project space, and the construction process. This plan shall include the

following:

1.2-4.8.1.1 A description of the impact of demolition and phasing on existing site functions and any

existing protection strategies and design interventions

1.2-4.8.1.2 An assessment of the need for temporary security barriers such as fencing and security

systems, including intrusion detection and video surveillance systems

1.2-4.8.1.3 A schedule for installation of security systems for completion during move-in activities to



allow for protection of the facility and equipment

1.2-4.8.2 Security Elements of the Safety Risk Assessment

*1.2-4.8.2.1 Design features. Design features shall address identified security risks specific to the patient

population to be served and environmental factors related to the project scope.

A1.2-4.8.2.1 Security elements of the safety risk assessment

a. Security considerations for project design

—Parking and exterior spaces. Hospital surroundings may include open space,

parking facilities, and private roadways and may border other businesses,

residential properties, or major transportation routes. Lighting design should be

provided for parking and exterior spaces.

—Buildings and interior spaces. In addition to patient care areas, hospitals may

include non-patient care areas such as academic and research space. These

areas may present specific risks or security concerns. The physical design of

buildings and integration of electronic security systems in the built

environment are important components of the facility protection plan and the

patient, visitor, and staff experience.

• Security plan. The project design should include a comprehensive

security plan that indicates a layered approach to access control,

including zones, control points, circulation routes, and required egress

paths.

• Protected health information. The design of hospitals should address all

forms of confidential patient information commonly referred to as

protected health information (PHI). The design should address the ways

in which this information could be compromised and should apply

integrated physical and electronic security systems (e.g., access control

and audit features) to locations such as registration, interview, clinical,

storage, and waste areas as well as in data systems.

• Utility and mechanical systems and other infrastructure. The risk

assessment should address the need to secure spaces and systems that

provide for system reliability and, as required, redundancy. The design of

utility, mechanical, and infrastructure-related spaces in hospitals should

include the recognition that such spaces and the mechanical, electrical,

plumbing, and information technology (IT) systems in them are critical

assets for the provision of uninterrupted patient care, basic building

comfort, and extraordinary emergency response capabilities.

• Biological, chemical, and radioactive materials. Areas in hospitals

containing highly hazardous materials frequently are regulated and

should be designed accordingly. Their design also should address the

unique security risks presented by highly hazardous materials (e.g.,

biological, chemical, and radioactive materials) that may be present in

patient care, laboratory, hazardous waste storage, or other locations.

b. Security for emergency management. Hospitals frequently provide both

scheduled and emergency services, serve as part of local emergency response

networks, and are expected to be functional, safe, and secure for patients,



visitors, and staff while remaining prepared for natural and man-made

emergencies 24 hours a day.

—The design of the facility should address the facility’s role in responding to

internal and external emergencies on its own or in coordination with local

emergency response or public health authorities based on assessed risks. All

other regulations for emergency operations should be considered when

developing the design.

—An all-hazards approach to design should be applied to help the facility

prepare for, respond to, and recover from man-made events and natural

disasters.

*1.2-4.9 Acoustics and Noise Safety Risk Assessment

A1.2-4.9 Acoustics and noise safety risk assessment. As a best practice,

acoustical requirements and noise levels should be assessed and documented by

the SRA team during the early planning stages of the project, so the facility

design results in reduced noise and vibration and increased safety.

a. Acoustics and noise risk assessment overview

⎯An acoustics and noise risk assessment should include the evaluation and

selection of the building shell type, interior wall and floor-ceiling

constructions, surface finishes, and building systems (i.e., mechanical,

plumbing, pneumatic, and lighting) that directly affect speech privacy, speech

intelligibility, and ultimately the safety of the patient and staff.

⎯Acoustics and noise control are matters of public health concern that require

assessment of the risks associated with noise exposure during planning and

design of health care facilities. On February 10, 2017, the Centers for Disease

Control and Prevention published Vital Signs, “Too Loud! For Too Long!” and

classified noise-induced hearing loss (an outcome of exposure to levels of

environmental noise) a serious public health matter. Health effects documented

in medical and public health literature range from heart disease and myocardial

infarction to elevated stress hormones and increased risk of falls.

b. Noise and vibration elements. Elements of an acoustics risk assessment should

include:

⎯Determination of building shell construction based on noise and vibration at

the site

⎯Review of interior spaces and relative noise levels to determine sound isolation

requirements between spaces for speech privacy

⎯Assessment of locations where noise and vibration can impact safety (e.g.,

medication safety zones)

⎯Evaluation of the building systems to determine strategies to control noise and

vibration



⎯Review and identification of interior spaces based on use, with

recommendations for acoustical finishes to reduce noise and increase speech

intelligibility

c. Noise and vibration design features. The SRA team should identify acoustical

design features deployed to meet the acoustical requirements for the building

type.

⎯Acoustical design features for a project may include:

• Sound-rated windows for facilities with a heliport or located near a

highway

• Wall and/or floor-ceiling partitions with increased sound transmission

class (STC) rating to reduce noise and increase privacy

• Interior acoustical finishes to reduce reverberation and increase speech

intelligibility in the room

• Vibration isolation of building mechanical and plumbing systems

d. Noise and vibration response. The design team should incorporate the noise

and vibration control elements in the project design documents.

1.2-5 Environment of Care Requirements

In addition to the functional requirements of the space being designed, the following components and key

elements of the physical environment shall be evaluated during project planning and design. The

evaluation shall be documented.

*1.2-5.1 Delivery of Care Model Concepts

A1.2-5.1 Delivery of care model concepts. Examples of delivery of care models

include patient-centered care, family-centered care, and community-centered

care. Information on the patient- and family-centered care model can be found at

the Institute for Patient- and Family-Centered Care website. Several examples of

other models of care can be found in Innovative Care Delivery Models:

Identifying New Models that Effectively Leverage Nurses, a report funded by the

Robert Wood Johnson Foundation.

1.2-5.1.1 A description of the delivery of care model shall be provided.

1.2-5.1.2 A description of the physical elements and key functional relationships necessary to support the

intended delivery of care model also shall be provided.

*1.2-5.2 Patients, Visitors, Physicians, and Staff Accommodation and Flow

Design criteria shall be described for the physical environment necessary to accommodate facility users

and administration of the delivery of care model.

A1.2-5.2 User accommodation. In evaluating the users of the facility, inclusive

design features should be considered in the context of the intended users’



characteristics (e.g., age, body size, ability, cultural background, gender identity).

*1.2-5.3 Building Infrastructure and Systems Design

Design criteria for the physical environment necessary to support organizational, technological, and

building systems that facilitate the delivery of care model shall be described.

A1.2-5.3 Physical relationships between services or new aggregations of services

should be clearly defined and supported. Clustering of related services affects the

criteria for design of the physical environment. Information technology, medical

technology, and/or staff use and cross training are issues that should be addressed

in relation to the environment of care components.

1.2-5.4 Physical Environment Elements

Descriptions of and/or design criteria for the following shall be provided:

*1.2-5.4.1 Light

How the use and availability of natural light and illumination are to be considered in the design of the

physical environment

A1.2-5.4.1 Light. Provisions of for natural light should be considered wherever

possible in the design of the physical environment. Visual benefits include

sufficient light for vision and safety; non-visual benefits relate to psychological

and/or biological factors (e.g., circadian rhythms).

a. Access to natural light should be provided no farther than 50 feet (15.24

meters) from any patient activity area, visitor space, or staff work area. To the

extent possible, the source of such natural light should also provide opportunities

for exterior views.

b. Access to natural light should be available without entering private spaces (i.e.,

staff should not have to enter a patient room to have access to natural light).

Examples of such access include windows at the ends of corridors, skylights into

deep areas of the building in highly traveled areas, transoms, and door sidelights.

c. Increasingly, technology may be able support circadian rhythms through

building standards and health care design. Numerous nationally recognized

organizations have developed circadian rhythm lighting standards, including

Underwriter’s Laboratories, Illuminating Engineering Society (IES), and the

Lighting Research Center.

cd. Artificial lighting strategies. IES has developed two publications that apply to

hospitals. ANSI/IES RP-29: Lighting for Hospitals and Health Care Facilities

addresses as a recommended practice for lighting for the general population

health care facilities and special lighting for medical procedures. ANSI/IES RP-

28: Lighting and the Visual Environment for Seniors and the Low Vision

Population addresses to address the special lighting needs of older adults these

care populations.

d. Color rendering properties should be addressed in lamp selection.

e. Finish selection should address light reflectance values (LRV) in conjunction



with lamp selection.

f. Indirect lighting should be considered to reduce glare.

*1.2-5.4.2 Views of and Access to Nature

How the use and availability of views and other access to nature are to be considered in the design of the

physical environment

A1.2-5.4.2 Views of and access to nature. Siting and organization of the

building should respond to and prioritize unique natural views and other natural

site features.

a. Ideally, the design for a hospital would include direct physical access to the

outdoors as well as views of nature and indoor gardens/atria. When direct access

is not possible, suitable alternatives could include indoor gardens with natural

light (atria) and visual access to nature, as defined by Green Guide for Health

Care Environmental Quality Credit 8.2 and Sustainable Sites Initiative Credit

6.7.

b. Separate outdoor respite areas for medical and support staff should be

provided. For practical guidelines for the percentage of space allocated for these

areas, refer to LEED for Health Care and Green Guide for Health Care

requirements as well as Sustainable Sites Initiative Credit 9.1.

c. Hospitals should provide a garden or other controlled exterior space that is

accessible to building occupants. Consider specifically designed therapeutic and

restorative gardens for patients and/or caregivers, as appropriate. Exterior spaces

should be located to accommodate staff observation. Therapeutic and restorative

gardens should be designed by landscape architects with knowledge and

experience specific to health care design as part of the multidisciplinary design

team.

d. Opportunities for active as well as passive interaction with nature in outdoor

space(s) should be provided (e.g., opportunities for exercise and play or other

types of physical activity and for physical, occupational, horticultural, or other

therapies).

e. Signage, other wayfinding features, and/or views of outdoor garden(s) and/or

atria should be provided to encourage their use.

f. Access to both sun and shade, with trees and/or built shade structures, should

be provided. Shady places are particularly important for patients who are

photosensitive.

g. When access to outdoor space is not restricted, automatic door openers, flat

door thresholds, and other physical connections between indoors and outdoors

that facilitate easy access should be provided.

h. Use of harmful and poisonous plants should be avoided, especially in gardens

for children, the developmentally disabled, and people with dementia, and

behavioral and mental health patients.



*1.2-5.4.3 Wayfinding

How clarity of access will be provided for the entire campus or facility using a wayfinding system. See

Section 1.2-6.3 (Wayfinding) for more information.

A1.2-5.4.3 Wayfinding

a. Hospital entry points should be clearly identified from all major exterior

circulation modes (e.g., roadways, bus stops, vehicular parking).

b. Clearly visible and understandable signage, icons, universal symbols, visual

landmarks and/or cues for orientation (including views to the outside) should be

provided. Consider accommodating the needs of various care populations (e.g.,

the elderly, children, cognitively impaired, visually impaired, and other

particularly vulnerable populations, including people with dementia) via the

provision of:

—Varied presentations of the same information (e.g., to accommodate users with

different cognitive processes)

—Accommodations for persons with limited English proficiency, including

speakers of other languages and those with limited reading ability

c. Boundaries between public and private areas should be well marked or implied

and clearly distinguished.

d. A system of interior “landmarks” should be developed to aid occupants in

cognitive understanding of destinations. To be effective, landmarks should be

unique and used only at decision points. Landmarks may include sealed water

features, major art, distinctive color, or decorative treatments. These features

should attempt to involve tactile, auditory, and language cues as well as visual

recognition. When color is used as a wayfinding device, it should support the

primary wayfinding system elements and be clearly distinguished from color

palette decisions unrelated to wayfinding.

e. Signage systems should be flexible, expandable, adaptable, and easy to

maintain. Signage should be consistent with other patient communications and

supporting print, Web, and electronic media.

*1.2-5.4.4 User Control of Environment

How, by what means, and to what extent users of the finished project will be able to control their

environment

A1.2-5.4.4 User control of environment. Opportunities for individual control

over as many elements of the environment as possible and reasonable (e.g.,

temperature, lighting, sound, and privacy) should be evaluated during functional

programing.

a. Lighting in patient and staff areas should allow for individual control and

provide variety in lighting types and levels.

—Patients should have control at bedside of over-bed, ceiling, and/or wall sconce

lighting.



—Patients should have control of varied lighting in patient bathrooms.

—Staff should have control of varying lighting levels in corridors outside patient

rooms, at caregiver substations, and at central caregiver stations to ensure that

patient sleep is not disturbed by general lighting not under the control of

patients/visitors.

—In single-patient rooms, it is preferable for patients to be able to control access

to natural light from the bedside.

b. Building systems design should address individual control over the thermal

environment through carefully considered zoning of mechanical systems that

permits control of heating and cooling to achieve thermal comfort for individual

patients and for staff in staff areas.

c. Noise has been proven to be an environmental stressor for patients, families,

and staff; therefore, the effects of noise should be a high priority in the design of

the physical environment and the selection of operational systems and

equipment.

—Where feasible and clinically safe to do so, patients should be able to have

some control of their acoustic environment. Noisy equipment and systems

should be controllable at bedside whenever possible and appropriate. Staff

should be able to switch medical alarms and communication equipment such

as paging and nurse call systems to staff communication devices and/or to an

acoustically protected room or area under caregiver supervision.

—Use of personal mobile devices should be considered in place of overhead

paging systems.

—Patients and staff should be able to activate sound-masking technology to help

mask unwanted sounds that affect the patient environment.

—Noise-canceling headsets or hearing protection devices should be available for

patient use.

—In waiting areas with television, alternate listening devices should be available

to offer patients a choice of quiet.

d. Personal storage. When length of stay is extensive, accommodations for

patients’ personal belongings should be provided. Staff should have a place to

secure their personal belongings.

*1.2-5.4.5 Privacy and Confidentiality

How privacy and confidentiality for users of the finished project are to be protected

A1.2-5.4.5 Privacy and confidentiality. Patient privacy is a right that has been

established through the Health Insurance Portability and Accountability Act

(HIPAA), which is intended to ensure that privacy of protected health

information (PHI) is maintained in all health care settings.

a. Public circulation and staff/patient circulation should be separated wherever

possible.



b. Waiting areas for patients on stretchers or in gowns should be located in a

private zone within the plan, out of view of the public circulation system.

c. Private alcoves or rooms should be provided for all communication concerning

personal information relative to patient illness, care plans, and insurance and

financial matters.

d. In facilities with multiple-patient rooms, family consultation rooms, grieving

rooms, and/or private alcoves in addition to family lounges should be provided to

permit patients and families to communicate privately.

e. In multiple-patient rooms or other areas where privacy cannot be ensured,

patients and/or staff should have smart technology (e.g., tablet or laptop)

available as an alternative to verbal communication.

*1.2-5.4.6 Security

How the safety and security of patients, staff, and visitors are to be addressed in the overall planning of

the facility

A1.2-5.4.6 Security

a. Provision of readily accessible and visible external access points to the facility

should be balanced with the ability to control and secure all access points in the

event of an emergency. Factors such as adequate exterior lighting in parking lots

and at entry points to the facility and appropriate reception/security services are

essential to ensuring a safe environment.

b. Since the strict control of access to a hospital is neither possible nor

appropriate, safety within the facility also should be addressed through the design

of circulation paths and functional relationships.

c. Provisions should be made for securing the personal belongings of staff,

visitors, and patients.

d. The physical environment should be designed to support the overall safety and

security policies and protocols of the institution.

e. Security monitoring, when provided, should respect patient privacy and

dignity.

*1.2-5.4.7 Architectural Details, Surfaces, and Built-In Furnishings

Characteristics and criteria for use in selecting materials and products for architectural details, surfaces,

and built-in furnishings

A1.2-5.4.7 Characteristics and criteria for selecting surface materials and

products. The effect of surface materials, colors, textures, and patterns on

patient, staff, and visitor safety and on maintenance and life cycle performance

should be considered in the overall planning and design of hospitals. See

appendix sections A2.1-7.2.3 (Surfaces—Characteristics and criteria for selecting

surface and furnishing materials and products) and A2.1-7.2.4-a (Furnishings—

Characteristics and criteria for selecting furnishing materials and products) for

details on selecting surface materials for hospitals.



*1.2-5.4.8 Cultural Responsiveness

How the project addresses and/or responds to local or regional cultural considerations including the

demographics and culture of patients, staff, and visitors

A1.2-5.4.8 Cultural responsiveness

a. Organizational culture is defined by the history of the organization, leadership

philosophy, management style, and caregivers’ dispositions. Also consider the

clinical function being served (e.g., pediatrics, geriatrics, oncology, obstetrics).

b. Regional culture is defined by the physical location and demographics

(including age, nationality, religion, and economics) of the communities served.

c. Cultural responsiveness to community-specific issues such as demographic

density in urban, suburban, and rural communities should be considered.

Demographics include the diversity of the local population and individual users’

characteristics (e.g., age, body size, ability, cultural background, gender identity)

in relationship to the design of an inclusive environment.

1.2-6 Planning and Design Considerations and Requirements

1.2-6.1 Acoustic Design

*1.2-6.1.1 General

The planning and design of new hospitals and the retrofitting of existing hospitals shall conform to the

Guidelines and all applicable codes and regulations with respect to exterior environmental sound and

interior sound within all occupied building spaces.

A1.2-6.1.1 Acoustic design

a. The definitions of acoustics terms used in this publication most often are based

on ANSI S1.1: Acoustical Terminology. See Sound and Vibration 2.0 , published

by Springer-Verlag, for the glossary of acoustic terminology used in this

document.

b. Limits set by codes often are expressed as maximum A-weighted sound levels

in dBA. Separate limits are typically set for day and night periods, with the

nighttime limit typically 5 to 10 dBA lower than the daytime limit. Daytime

limits typically vary between 55 and 65 dBA.

c. Following are some acoustic design codes, regulations, and guidelines that

should prove useful for hospitals:

—U.S. Department of Health and Human Services regulations (including

HIPAA)

—Federal Aviation Administration (FAA) guidelines for helipad design,

construction, and operation

—Guidelines for noise in NICUs in sections 2.2-2.8.7.1 (Architectural details)

and 2.2-2.8.7.3 (Noise control)



—Building code used by the local or state jurisdiction

—Local and state limits on environmental sound

—Occupational Safety and Health Administration (OSHA) regulations for

worker noise exposure in areas where sound levels exceed 85 dBA

—Professional society design guidelines for noise (e.g., American Society of

Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) guidelines

for mechanical system sound and vibration control)

—American National Standards Institute (ANSI) guidelines for sound in building

spaces and special spaces (e.g., booths for measuring hearing threshold)

—Manufacturers’ guidelines for medical equipment that is sensitive to sound and

vibration or equipment that produces sound and/or vibration

*1.2-6.1.2 Site Exterior Noise

A1.2-6.1.2 Site exterior noise. This section provides design guidance on how to

address environmental noise at a facility site over which the facility may or may

not have administrative or operational control. This section is meant to provide a

means for screening sites to help determine which exterior wall/window

assemblies are suitable to address site noise; it is not intended to be used as a

means to qualify the suitability of a site with respect to environmental noise

exposure.

Examples of noise sources a facility should control include the power plant,

HVAC equipment, and emergency generators that are part of the hospital. An on-

site noise source over which the facility may have limited control is helipads. The

location and operation of helipads are subject to federal regulation and other

safety and environmental considerations. Examples of noise sources a facility

cannot control include highways, rail lines, airports, and general urban,

industrial, and public service equipment and activities.

*1.2-6.1.2.1 Existing exterior noise sources. Planning and design of new facilities and retrofitting of

existing facilities shall include due consideration of all existing exterior noise sources that may be

transmitted from outside a building to its interior through the exterior shell (i.e., exterior walls, windows,

doors, roofs, ventilation openings, and other shell penetrations).

A1.2-6.1.2.1 In addition to existing exterior noise sources, hospital design should

consider future noise source development, such as the construction of highways,

airports, or rail lines in the vicinity of the project.

1.2-6.1.2.2 Facility noise source emissions

*(1) Planning and design shall include due consideration of sound emissions from hospital noise sources

that reach nearby residences and other sensitive receptors. See Section 2.1-8.3.3.1 (3) (Acoustic

considerations for generators) for more information.

A1.2-6.1.2.2 (1) Sound from exterior facility equipment can be minimized to

achieve acceptable sound levels inside hospital spaces and at neighboring

receptors by siting noise sources and receptors to take advantage of distance,



orientation, and shielding. Sound from exterior facility equipment also can be

reduced by selecting quiet equipment and making use of noise control equipment

such as silencers and barriers.

*(2) Acoustic considerations for outdoor mechanical equipment

(a) Outdoor mechanical equipment shall not produce sound that exceeds 65 dBA at the hospital

façade, unless special consideration is given to façade sound isolation design in impinged areas.

(b) Outdoor mechanical equipment shall not produce sound that exceeds daytime and nighttime noise

limits at neighboring properties as required by local ordinance.

A1.2-6.1.2.2 (2) Acoustic considerations for outdoor mechanical equipment.

Outdoor mechanical equipment includes cooling towers, rooftop air handlers,

exhaust fans, and fans located inside buildings with openings on the outside of

the building. Noise that these and other outdoor equipment produce may impinge

on hospital buildings and require special consideration of the hospital building

shell in these areas, or may impinge on adjacent properties where jurisdictional

noise limits and/or owner land uses must be considered.

*1.2-6.1.2.3 Exterior noise classifications

(1) Exterior noise classification shall be used to identify the degree of sound attenuation required in the

building façade due to sources of exterior noise. Exterior site noise exposure categories shall be as

identified in Table 1.2-3 (Categorization of Hospital Sites by Exterior Ambient Sound with Design

Criteria for Sound Isolation of Exterior Shell in New Construction).

(2) The building façade shall have a sound isolation rating (dependent on the site’s noise classification

category) that complies with minimum exterior shell composite sound transmission ratings, either

OITCc or Stock, as shown in Table 1.2-3.

A1.2-6.1.2.3 Exterior noise classifications. By means of exterior site

observations or a sound-level monitoring survey and knowledge of new noise

sources to be included in the design of the facility, the facility site should be

classified into one of the noise exposure categories in Table 1.2-3 (Categorization

of Hospital Sites by Exterior Ambient Sound…). Further information for

classifying sites according to exterior noise can be found in appendix table A1.2-

b (Approximate Distance of Noise Sources for Use in Categorization of Hospitals

by Exterior Ambient Sound).

a. The sound levels for noise exposure categories A through D provided in Table

1.2-3 and appendix table A1.2-b should be used to evaluate required health care

building envelope sound isolation and may differ from other such categorizations

of community noise made elsewhere in this document.

Category A—Minimal environmental sound. As typified by a rural or quiet

suburban neighborhood with ambient sound suitable for single-family residences,

sound produced by transportation (highways, aircraft, and trains) or industrial

activity may occasionally be audible but is only a minor feature of the acoustic

environment.

Category B—Moderate environmental sound. As typified by a busy suburban



neighborhood with ambient sound suitable for multifamily residences, sound

produced by transportation or industrial activity is clearly audible and may at

times dominate the environment but is not loud enough to interfere with normal

conversation outdoors.

Category C—Significant environmental sound. As typified by a commercial

urban location, possibly with some large apartment buildings, sound produced by

transportation or industrial activity dominates the environment and often

interferes with normal conversation outdoors.

Category D—Extreme environmental sound. As typified by a commercial urban

location immediately adjacent to transportation or industrial activities, sound

nearly always interferes with normal conversation outdoors.

b. Environmental noise on Category B, C, and D sites generally may be evaluated

using the methods given for documenting site ambient sound levels using

continuous sound monitoring over a minimum one-week period in ANSI/ASA

S12.9: Quantities and Procedures for Description and Measurement of

Environmental Sound, Part 2: “Measurement of Long-Term, Wide-Area Sound.”

This information should be used to determine detailed environmental noise

control requirements for building design. Sites where ambient sound is

influenced by airport operations may require additional monitoring as suggested

in the ANSI standard to account for weather-related variations in aircraft sound

exposure on site. In lieu of performing such additional monitoring, aircraft sound

level contours available from the airport (if available) should be used to

determine the day–night average sound level on site produced by nearby aircraft

operations. Sound-level monitoring on site will still be needed to determine

sound levels produced by other sources.

c. Table 1.2-3 and appendix table A1.2-b present general descriptions for exterior

sound exposure categories A through D, including distance from major

transportation noise sources, ambient sound levels produced by other sound

sources, and corresponding design goals for the sound isolation performance of

the exterior building shell.

The outdoor sound levels, expressed as A-weighted day–night average sound

levels, are provided in the context of exterior building shell design. Outdoor

patient areas may require lower sound levels, typically not exceeding a day–night

average level of 50 dB. To achieve this may require accommodations such as

exterior noise barriers or location of outdoor patient areas where the building

structures provide shielding from noise sources.

d. In most cases, following the requirements in Table 1.2-3 will result in interior

day-night average sound levels (Ldn) from exterior sources that are less than or

equal to 45 dBA. Actual results will vary depending on how well the sound-

blocking ability of the shell at various frequencies matches the sound spectrum of

the outdoor sound and other factors such as area of the exposed façade and

absorption in the room.

Some rooms require lower sound levels, such as assembly spaces, patient rooms,

clinical spaces, quiet rooms, and similar noise-sensitive rooms. These room types

should be carefully evaluated to reduce the contribution of outdoor noises



transmitted inside while also considering the noise levels from the building

systems (see Table 1.2-5: Maximum Design Criteria for Noise in Interior Spaces

Caused by Building Systems). Assemblies meeting the minimum OITCc

requirement will typically provide better performance when the outdoor sound is

dominated by sources with strong low-frequency sound (e.g., locomotives or

slow-moving heavy trucks). Assemblies meeting the minimum STCc

requirement typically provide better performance when strong low-frequency

sound is not present.

More detailed evaluation should be considered to identify which sound isolation

rating (OITCc or STCc) is preferred to meet the exterior shell acoustic

requirements and potentially provide a more cost-effective design.

*1.2-6.1.3 Design Criteria for Acoustic Surfaces

All normally occupied hospital spaces shall incorporate floor, wall, or ceiling acoustic surfaces that

achieve design room-average sound absorption coefficients equal to or greater than indicated in Table

1.2-4 (Minimum Design Room-Average Sound Absorption Coefficients).

A1.2-6.1.3 Design criteria for acoustic surfaces

a. Alarm fatigue. The need to reduce or eliminate “alarm fatigue” has been

recognized as a top priority in hospitals. FDA incident reports demonstrate that

alarm fatigue can cause dangerous and potentially life-threatening behaviors,

including willful deactivation of clinical alarms; increased error rates due to

impaired communication; disorientation, distraction, and elevated stress that

induce fatigue; and—for patients—loss of sleep, heightened anxiety, and

increased sedative use. Room conditions contribute to alarm fatigue, which is

caused by multiple, frequent, uncorrelated, and highly arousing noises from

alarms and other sources mixing and reverberating in enclosed spaces with

surfaces that are highly sound-reflective (i.e., do not absorb sound reverberation).

Table 1.2-4 (Minimum Design Room-Average Sound Absorption Coefficients)

specifies the sound absorption coefficients needed to reduce the potential for

alarm fatigue.

b. Operating rooms. The acoustic environment of operating rooms should be

designed to reduce reverberation, noise buildup, and noise-related fatigue. The

design room sound absorption coefficient in operating rooms should be at least

0.10.

1.2-6.1.4 Design Criteria for Room Noise Levels

*1.2-6.1.4.1 Room noise levels caused by HVAC and other building systems shall not exceed the

maximum values shown in Table 1.2-5 (Maximum Design Criteria for Noise in Interior Spaces Caused by

Building Systems).

A1.2-6.1.4.1 Room noise levels in operating rooms. A sound level lower than

NC/RC(N)/RNC 45 (50 dBA) in operating rooms should be considered.

However, because HVAC systems may result in sound levels higher than this,

extraordinary system design and construction might be needed to achieve a lower

level than the requirement in Table 1.2-5 (Maximum Design Criteria for Noise in

Interior Spaces Caused by Building Systems) in operating rooms.



1.2-6.1.4.2 Room noise levels shall be determined for the unoccupied room (i.e., without operating

medical equipment).

1.2-6.1.5 Design Criteria for Performance of Interior Wall and Floor/Ceiling Constructions

1.2-6.1.5.1 Sound isolation shall be considered for all demising construction separating occupied spaces.

*1.2-6.1.5.2 The composite sound transmission class (STCc) rating of demising wall assemblies shall not

be less than the ratings indicated in Table 1.2-6 (Design Criteria for Minimum Sound Isolation

Performance Between Enclosed Rooms).

A1.2-6.1.5.2 Demising wall assemblies

a. A “demising wall assembly” is a partition that separates one occupancy or

health care service from another occupancy/service or a corridor. Partitions

within the same occupant space or health care service space are non-demising

partitions. For example, the partition between two patient rooms or two exam

rooms is demising, but the partition between a patient room and its private

bathroom is non-demising.

b. Appropriate steps should be taken to assure that the composite STC sound

isolation performance of demising wall assemblies in Table 1.2-6 (Design

Criteria for Minimum Sound Isolation Performance Between Enclosed Rooms) is

achieved after consideration of perimeter leaks due to lack of sealing, flanking

due to continuous surfaces extending from one room to the other, sound passing

through a plenum above a wall, or penetrations in the wall or ceiling. Particular

attention should be given to intersection and sealing details of demising wall

assemblies.

*1.2-6.1.6 Design Guidelines for Speech Privacy

A1.2-6.1.6 Speech privacy

a. Federal legislation requires that facilities protect patient privacy. This includes

speech privacy in all health care venues or wherever protected health information

is discussed, either between staff, on the telephone, or during dictation.

b. Speech privacy in open-plan spaces. People working in open-plan spaces are

most productive when distraction from voices, equipment, etc. is minimal.

Therefore, the acoustic environment should be designed to minimize such

distractions. One option for achieving speech privacy in open-plan spaces is

provision of a separate room where conversations may take place in private.

*1.2-6.1.6.1 Speech privacy rating methods. Spaces shall be designed to meet speech privacy goals

using one of the four speech privacy rating methods as shown in Table 1.2-7 (Design Criteria for Speech

Privacy for Enclosed Rooms and Open-Plan Spaces).

A1.2-6.1.6.1 Methods for determining speech privacy. Select only one of the

metrics in Table 1.2-7 (Design Criteria for Speech Privacy for Enclosed Rooms

and Open-Plan Spaces) for determining speech privacy in closed- and open-plan

settings. Examples of closed-plan settings are medical staff private offices,

conference rooms, examination rooms, and single-patient rooms. Examples of

open-plan settings are patient waiting areas, reception areas, and medical staff



open (not fully enclosed) offices.

All four metrics in Table 1.2-7 define speech privacy in terms of the

intelligibility of speech from the transmitted speech signal compared to the

continuous background sound at a receptor position. Each of the metrics

represented in the table is an accepted industry practice, and equivalence has

been demonstrated. The choice and use of the selected metric should be made by

qualified, experienced professionals.

a. Criteria for the AI (Articulation Index) metric were originally defined in ANSI

S3.5-1969: Methods for the Calculation of the Articulation Index but are now

defined in ASTM E1130: Standard Test Method for Objective Measurement of

Speech Privacy in Open Plan Spaces Using Articulation Index. This metric has

been in use since the mid-1950s and is still considered a current practice.

b. Criteria for the SII (Speech Intelligibility Index) metric are defined in ANSI

S3.5-1997: Methods for Calculation of the Speech Intelligibility Index.

c. Criteria for the SPC (Speech Privacy Class) metric are defined in ASTM

E2638-10: Standard Test Method for Objective Measurement of the Speech

Privacy Provided by a Closed Room and “ASTM Metrics for Rating Speech

Privacy of Closed Rooms and Open Plan Spaces,” an article from the September

2011 edition of the Journal of the Canadian Acoustical Association.

d. Criteria for the PI (Privacy Index) metric for converting AI values into

percentages are defined in ASTM Standard E1130-08: Standard Test Method for

Objective Measurement of Speech Privacy in Open Plan Spaces Using

Articulation Index.

*1.2-6.1.7 Design Criteria for Building Vibration

A1.2-6.1.7 Building vibration

a. Building vibration refers to vibration produced by building equipment and

activities, not vibration produced by earthquakes.

b. Vibration levels to which occupants are exposed should not exceed those in

ANSI S2.71: Guide to the Evaluation of Human Exposure to Vibration in

Buildings.

c. Vibration produced by building mechanical, plumbing, and electrical

equipment; footfalls; road and/or rail traffic; and medical equipment should be

considered in the design of a hospital.

1.2-6.1.7.1 General. Seismic restraint covered elsewhere in this document shall be compatible with

vibration isolation methods covered in this section.

1.2-6.1.7.2 Vibration control and isolation. Vibration levels in the building shall not exceed applicable

guidelines and limits outlined in this section.

(1) Mechanical, electrical, and plumbing equipment vibration

(a) All fixed building equipment that rotates or vibrates shall be considered for vibration isolation.



(b) Mechanical equipment, ductwork, and piping shall be mounted on vibration isolators as required to

prevent unacceptable structure-borne vibration.

(c) Equipment bases, isolators, and isolator static deflections shall be selected based on the proximity

of the supported equipment to vibration- and noise-sensitive areas, structural design of the facility,

and type and operating point of the equipment.

(i) The recommendations in the ASHRAE Handbook—HVAC Application shall be considered when

selecting types of bases, isolators, and isolator static deflections.

(ii) More stringent requirements shall be considered for equipment impacting sensitive areas.

(2) Structural vibration

(a) Footfall vibration in the building structure shall be evaluated using properly substantiated methods

of analysis, including:

(i) For steel floor systems: American Institute of Steel Construction (AISC) Design Guide 11:

Vibrations of Steel-Framed Structural Systems Due to Human Activity

(ii) For concrete floor systems: Concrete Reinforcing Steel Institute (CRSI) Design Guide for

Vibrations of Reinforced Concrete Floor Systems

(iii) If neither (i) nor (ii) is applicable, use of finite element analysis (FEA) or modal superposition

analysis methods shall be considered.

(b) The structural floor shall be designed to avoid footfall vibration levels that exceed the peak

vibration velocities in Table 1.2-8 (Maximum Limits on Floor Vibration Caused by Footfalls in

Hospitals).

(c) More stringent vibration criteria shall be considered for locations where vibration-sensitive medical

and laboratory instrumentation is housed.

(3) Structure-borne sound

(a) Structure-borne transmitted sound shall not exceed the limits for airborne sound presented in

Section 1.2-6.1.4 (Design Criteria for Room Noise Levels).

(b) Where necessary, vibration isolators shall be used to control potential sources of structure-borne

sound.

(4) Ground-borne vibration. Exterior sources of ground vibration, such as road and rail traffic, shall be

considered in the site selection and design of a facility. See Chapter 1.3 (Site) for additional

requirements.

*1.2-6.2 Sustainable Design

Sustainable design, construction, and maintenance practices to improve building performance shall be

considered in the design and renovation of hospitals.

A1.2-6.2 Sustainable Design. Planning and design for new and renovated

hospitals may include the establishment of sustainability goals by a

multidisciplinary team.



a. A growing body of knowledge is available to assist design professionals and

health care organizations in understanding how buildings affect human health

and the environment and how these effects can be mitigated through a variety of

strategies. To meet these objectives, health care organizations should use an

integrated project delivery process and develop a multidisciplinary design team

to guide facility design.

The International Code Council has developed the International Green

Construction Code (IgCC), which has been adopted by numerous states and

municipalities. The IgCC includes content from ANSI/ASHRAE/ASHE 189.3:

Standard for the Design, Construction and Operation of Sustainable High-

Performance Health Care Facilities.

b. Several codes, references, and green building rating systems apply to health

care settings, including but not limited to:

⎯The International Green Construction Code (IgCC), developed by the

International Code Council. The content for IgCC is directly from

ANSI/ASHRAE/USGBC/IES Standard 189.1: Standard for Design of High-

Performance Green Buildings, Except Low-Rise Residential Buildings.

⎯ANSI/ASHRAE/ASHE Standard 189.3: Standard for the Design,

Construction, and Operation of Sustainable High-Performance Health Care

Facilities. This standard references ANSI/ASHRAE/ICC/USGBC/IES Standard

189.1: Standard for Design of High-Performance, Green Buildings, Except Low-

Rise Residential Buildings with adapted and changed criteria specifically for

health care facilities.

a. ⎯LEED and Green Building Rating System (https://www.usgbc.org). This

U.S. Green Building Council has established this third-party certification

framework for the design of sustainable buildings. LEED® for Building Design

and Construction (BD+C) includes health care.

b. Green Guide for Health Care™, a voluntary self-certification metric tool that

specifically addresses the health care sector

⎯Green c. Green Globes assessment and rating system

(http://www.greenglobes.com)This interactive green building design tool

provided by the Green Building Initiative (GBI) incorporates an integrated

project management approach and offers third-party certification. GBI tools are

available for New Construction (NC) as well as Continual Improvement for

Existing Buildings (CIEB) for health care facilities. GBI has developed

ANSI/GBI 01: Green Building Assessment Protocol for Commercial Buildings to

inform the development of Green Globes rating systems.

⎯Fitwel (https://www.fitwel.org)

⎯WELL Building Standard (https://www.wellcertified.com)

⎯Sustainable Facilities Tool, General Services Administration

(https://sftool.gov)

http://www.greenglobes.com/

https://www.fitwel.org/

https://sftool.gov/



⎯For long-term care settings in hospital facilities the Senior Living

Sustainability Guide (includes pre-development guidelines, addresses four

dimensions (resident, organization, operations, and physical setting) within a

social-cultural context, and recommends continual improvement processes based

on benchmarks. http://www.withseniorsinmind.org)

These green building rating systems, regulations, and codes provide criteria for

the advancement of high performance, sustainable design, and health and

wellness opportunities in the built environment.

tools establish “best practice” criteria and provide planning, design, and

development process guidance for site design, water and energy usage, materials,

and indoor environmental quality.

1.2-6.2.1 Components

The basic components of sustainable design to be considered shall include:

*1.2-6.2.1.1 Site selection and development

A1.2-6.2.1.1 Site selection and development

a. Site development considerations include the following:

—Land use

—Storm water management

—Habitat preservation

—Landscape design and irrigation systems

—Shading

—Natural ventilation

—Renewable energy use

—Effects from heat islands

—Resilience based upon geographic location, building type, and risk (flooding,

weather, fire, etc.)

b. Daylighting. The orientation of buildings on the site should be evaluated to

determine how to make appropriate use of daylighting based on the care

population. Evaluate the net effect of planned daylighting on energy consumption

and operating cost. See Section 1.2-6.2.1.4 (Energy efficiency) for information.

c. Site exterior noise. The location of the buildings also should be evaluated in

regard to the impact of site exterior noise, acoustics, and the care population. See

appendix sSection A1.2-6.1.2 (Acoustic DesignSite exterior noise) for additional

information.

(1) The site design shall be developed to minimize negative environmental impacts associated with

buildings and related site development.

http://www.withseniorsinmind.org/



(2) The orientation of buildings on the site shall be evaluated to assess how solar and wind effects can be

harnessed to minimize energy consumption.

*1.2-6.2.1.2 Waste minimization. The design shall support the minimization of waste in construction

and operation and allocate space for recycling activities.

A1.2-6.2.1.2 Waste minimization. Many states and local jurisdictions mandate

waste management targets for commercial facilities and health care facilities.

Financial incentives are available to many health care facilities that prioritize

waste stream management. It will benefit hospitals to consider the space needs

associated with environmentally preferable purchasing and recycling programs to

better enable them to achieve these savings.

(1) Mercury reduction and waste

(a) Building products that are mercury-free and/or minimize mercury content shall be specified.

(b) In facilities delivering dental care, amalgam separation devices shall be installed that meet or

exceed the requirements of ISO-11143: Dentistry—Amalgam separators.

(c) An area shall be provided for storing holding mercury-containing products (e.g., lamps) until

disposalto be recycled.

(2) Construction waste management. A construction waste management plan shall be developed and

implemented.

(a) Materials shall be identified that can be recovered, reused, and/or recycled and a plan made to

divert them from disposal in landfills or incinerators.

(b) The disposal method shall be identified for each material, and whether materials will be sorted or

co-mingled on site shall be determined.

*1.2-6.2.1.3 Potable water quality and conservation

A1.2-6.2.1.3 Potable water quality and conservation

a. Conservation strategies. Potable water consumption can be reduced by using

low-consumption plumbing fixtures and controls, low-consumption irrigation

systems, and landscape design such as xeriscaping and by replacing items such as

water-cooled pumps and compressors that use potable water sources with non-

evaporative heat rejection equipment (air cooled or ground sourced) or

equipment that uses non-potable water sources.

b. Measurement and verification plan. To provide for long-term continuous

measurement of potable cold water uses in the facility, a measurement and

verification plan should be developed and implemented. The following water

uses (as applicable to the project) should be metered:

—Main water to site

—Special deduct meters, including those for cooling tower makeup, boiler

system makeup, boiler blowdown, other hydroponic loop makeup, irrigation

and emergency medical equipment cooling



c. Medical equipment. Except for backup systems, potable water should not be

used for primary once-through cooling for any medical equipment.

(1) Potable water quality and conservation strategies shall be evaluated in all phases of facility

development or renovation.

(2) Design for water conservation shall not adversely affect patient health, safety, or infection control.

(3) Plumbing fixtures and fittings for water reduction shall comply with ANSI/ASHRAE/ASHE 189.3:

Design, Construction, and Operation of Sustainable High-Performance Health Care Facilities,

Section 6.3.2.1 Plumbing Fixtures and Fittings.

(4) Vacuum pumps and air compressors. Potable water shall not be used for vacuum pumps and air

compressors.

*1.2-6.2.1.4 Energy efficiency. Mechanical and electrical systems shall be selected and sized to support

reduced energy demand and consumption. ANSI/ASHRAE/IES 90.1: Energy Standard for Buildings

Except Low-Rise Residential Buildings, as adopted by the U.S. Department of Energy, shall be used in the

absence of a locally or state adopted energy code.

A1.2-6.2.1.4 Energy efficiency ANSI/ASHRAE/IES 90.1: Energy Standard for

Buildings Except Low-Rise Residential Buildings, as adopted by the U.S.

Department of Energy, should be used in the absence of a locally adopted energy

code.

a. Energy efficiency goals. Health care organizations should set energy efficiency

goals (e.g., application of ASHRAE 90.1; design to earn Energy Star, Green

Globes, LEED for Healthcare, or LEED WELL Building Standard certification)

and consider energy efficiency strategies that include, but are not limited to, the

following examples.

—On major new projects, consider the use of energy modeling early in schematic

design to assist in developing and assessing energy efficient strategies and

opportunities.

—Reduce overall energy demand. Sample strategies for this purpose include

using a high-efficiency building envelope; passive and low-energy sources of

lighting (including daylighting); advanced lighting controls integrated with

daylighting strategies; high-efficiency equipment, both as part of building

mechanical and electrical systems (e.g., chillers and air handlers) and for plug

loads (e.g., Energy Star copiers, computers, medical equipment, and

appliances); heat recovery; and natural ventilation.

—Optimize energy efficiency. Mechanical/electrical control systems should

optimize consumption to the minimum actual needs of the building. Consider

using multiple modular HVAC equipment units or variable-speed drives for

variable loads. Consider co-generation systems for converting natural gas to

both heat (or cooling) and electricity. Select equipment with improved energy

efficiency ratings.

—Reduce environmental impacts associated with combustion of fossil fuels and

refrigerant selection. Consider various renewable sources of energy including

purchase of green power and on-site generation of solar and wind energy or



geothermal/ground source heat pumps.

b. Measurement and verification plan. In new construction, a measurement and

verification (M&V) plan to track energy use should be developed and

implemented. Metering that provides consistent and reliable data should be

considered for the following electrical and mechanical systems (as applicable to

the scope of the project):

—Gas

• Main gas line to the site

• Each natural gas boiler

• Kitchen gas

—Electricity

• Consumption (kWh) and demand (kW) for each source of electricity to

the building

• Metered loads at primary distribution switchgear and/or switchboards

• Metered loads at essential systems distribution equipment (paralleling

gear or switchgear and/or switchboards)

• Output from each automatic transfer switch

• Energy consumption for pump major mechanical, plumbing, and medical

gas equipmentfan for each motor with a variable frequency drive (VFD)

—Thermal energy

• All steam energy purchased from off-site sources, including recovered

condensate

• Steam produced by each steam boiler

• Hot water produced by each hot water boiler

• Chilled water output for each water chiller

—Energy source (fuel oil, solar, geothermal, propane, etc.) for each device listed

• Each steam or hot water boiler

• Each generator used for non-emergency purposes

*1.2-6.2.1.5 Indoor environmental quality

A1.2-6.2.1.5 Indoor environmental quality. Design for a healthy and

productive indoor environment should be accomplished through measures such

as adequate ventilation, low- or zero-VOC (volatile organic compound) finishes

and furnishings, reduced moisture entrapment, daylighting, and acoustic design



measures. Such measures should not conflict with health care safety and infection

control codes and standards.

See ANSI/ASHRAE/ASHE Standard 189.3: Standard for Design, Construction,

and Operation of Sustainable High-Performance Health Care Facilities, Section

8.4 Prescriptive Path for Emissions and VOCs, and ANSI/ASHRAE/USGBC/IES

Standard 189.1: Standard for Design of High-Performance, Green Buildings,

Except Low-Rise Residential Buildings (ASHRAE 189.1), Section 8.4.2

Materials. Carpeting, upholstery, paint, adhesives, and manufactured wood

products may emit VOCs such as formaldehyde and benzene. Use low- or zero-

VOC paints, stains, adhesives, sealants, and other construction materials, where

practical.

Materials or construction systems that are permeable and can trap moisture may

promote microbial growth. All permeable building materials should be protected

from exposure to moisture prior to and during construction. If permeable

materials are exposed to moisture, they should be dried within 72 hours or

removed.

High-volume photocopiers, portable sterilizing equipment, and aerosolized

cleaners and medications have been identified as important sources of indoor air

pollution in health care settings. Dedicated exhaust ventilation may be necessary

for specialty areas where these pollutants may accumulate or be disbursed (e.g.,

housekeeping, copying rooms, sterilization areas, etc.).

(1) The impact of building design and construction on indoor environmental quality shall be addressed.

(2) Impact from both exterior and interior air-contamination sources shall be minimized.

1.2-6.2.1.6 Environmental impact of selected building materials. The environmental impacts

associated with the life cycle of building materials shall be addressed.

*1.2-6.3 Wayfinding

A1.2-6.3 Wayfinding

a. During the functional programming process, input from frontline staff, facility

managers, visitors, families, and patients should be sought regarding wayfinding.

This should include evaluation of the most common and problematic scenarios to

identify shortcomings and help develop design criteria to address them.

Consideration should be given to the following:

—Needs of first-time users

—Stress experienced by patients and families while finding their way to

unfamiliar areas in a facility

—Populations served (e.g., the elderly; children; and cognitively impaired,

visually impaired, and other particularly vulnerable populations, including

those with Alzheimer’s and dementia)

—Needs of limited English proficient (LEP) individuals, speakers of other

languages, and those with limited reading ability. Where possible, use the



Universal Symbols in Health Care.

—Use of unique landmarks (e.g., design elements such as color, artwork, texture,

change in architecture, exterior views, plants)

—Varied presentation of the same information to accommodate different

cognitive processes (e.g., those used by different individuals or by the same

individuals at different points during the wayfinding process)

—Integration of the wayfinding plan with relevant security plans

b. Input from staff, visitors, families, and patients as described in Section 1.2-2

(Functional Program) should be integrated into the development of a systems

approach to wayfinding. Planning for wayfinding should begin with the goal that

the average visitor or staff member can easily find his or her way throughout the

facility. Outside wayfinding should be considered for those walking and for those

driving to the facility. If public transportation is available, directions and signage

to and from transportation sites should be provided.

c. General sign recommendations

—Exterior and interior approaches to wayfinding should be coordinated.

—Nomenclature should be consistent and understandable to the general public,

and signs generally should be written at a sixth-grade level.

—Information (a destination hierarchy) should be developed to ensure the right

information is presented at the right time.

— A family of signs should be developed for consistency within the wayfinding

system. This should include directional and orientation signs (e.g., overhead

and wall-mounted signs and maps), destination signs, room identification

signs, regulatory signs, and provisions for a multitude of hospital-specific

policy and information signs.

—Each sign should be accurate, legible, and functional:

• Letters should contrast with the background to conform to ADA

requirements. For signs in areas that primarily house the elderly, letters

should contrast with the background by a minimum of 90 percent.

• Colors should be differentiable by those who are color-blind.

• When used, symbols and pictographs should be recognizable to the general

public and the community served. (The Universal Symbols in Health Care

have been tested for usability and comprehension.)

• The number of symbols used on a single sign should be limited and

indicate primary destinations only.

• Destination hierarchies should manage the number of symbols by building,

zone, or floor. Users have difficulty differentiating more than 16 unique

symbols in one set.



• Where health care symbols are combined with other universal symbols

used in transportation or accessibility, the different sets of symbols should

be clearly differentiated.

d. You are here (YAH) map recommendations

—YAH maps should be oriented so that forward is up.

—It is preferable to use a perspective view. Where vertical navigation is

required, consider illustrating the relationship between levels and which

elevator cores serve which areas, especially where floors are not contiguous.

—Inset maps should be used to locate details within the overall map where

appropriate.

e. Exterior signage (general)

—Directional signs should be easily viewed from the street and located and sized

so that drivers can read them when traveling at the local speed limit.

—Consistency should be used in the nomenclature of buildings.

—Directions should be clear to all users.

—Signage should be within an individual’s 60-degree “cone of vision,” whether

the person is walking or driving.

—Exterior directional signs should be visible at night.

—Signage should be located where it is easy to see.

—Where applicable, emergency departments should be clearly distinguished

from other destinations.

f. Exterior signage (parking)

—Directions should be provided to various parking locations, where applicable.

—Directions should be provided from the parking structure to the entrance of the

facility.

—Signage should clearly indicate short-term and long-term parking rates, where

applicable.

—Valet parking, if provided, should be clearly marked.

—Directional signage should be provided for automobile and pedestrian traffic.

—Floor numbers or sections should be marked clearly.

g. Interior signage (entrance and exit)

—A well-designed and located set of interior signs and clearly labeled directional

maps should be located near the entrance. Symbols used on directional signage

should be used in orientation maps for consistency and to assist users in



finding primary destinations.

—Signage should clearly identify all publicly accessible functional areas of the

facility (e.g., cafeteria/dining, gift shop, restrooms, etc.).

—Where symbols are used, a single symbol should be used to represent a single

primary destination.

—There should be adequate signs to direct people out of the facility back to

parking and public transportation.

h. Interior wayfinding (room numbering)

—Room numbering should be consistent from floor to floor and area to area.

—The numbering system should be simple and continuous.

—Design of the numbering system should be flexible to allow for future

expansion and renovation.

— Room numbering should consider the need for sequential strategies for public

wayfinding that may be different from operational and maintenance

numbering.

—Signs should differentiate between those spaces used by patients/visitors and

those used by staff.

i. Interior wayfinding (sign placement)

—Signs providing directions should be placed at major decision points, including

the following:

• Major intersections

• Major destinations

• Changes in buildings

—If there are no major decision points, reassurance signs should be placed

approximately every 250 feet (76.2 meters).

j. Interior wayfinding (signage maintenance). Fabrication should be in a manner

that allows messages to be changed.

*1.2-6.3.1 An organized approach to wayfinding about the entire campus or facility shall be provided.

A1.2-6.3.1 An organized approach to wayfinding should include the following:

a. An integrated system that coordinates elements such as visible and legible

signs and numbers

b. Verbal directions, paper information, and electronic information

1.2-6.3.2 Where provided, exterior wayfinding shall clearly define the access pathways from public

thoroughfares to the main entrance and emergency department entrance. Signage shall be consistent with



all state, local, and federal regulations.

*1.2-6.4 Design Considerations for Accommodation of Individuals of Size

A1.2-6.4 Design considerations for accommodation of individuals of size

a. The patient’s weight, the distribution of the patient’s weight throughout the

body, and the patient’s height are involved in identifying a patient who requires

additional assistance, expanded-capacity equipment, and larger space for patient

care, moving, handling, and mobilization. Such patients are not necessarily

receiving bariatric care, thus the term “individual of size” is used. The most

commonly accepted method for clinically identifying individuals of size is the

body mass index (BMI).

b. Creating health care environments that can accommodate individuals of size

requires attention to issues that significantly affect design, such as the nature of

the clinical unit or area, current codes, and local regulations. Refer to appendix

sections A1.2-6.4.1.1 (Projecting the weight capacities of individuals of size to

be served), A1.2-6.4.1.2 (Projecting the number of spaces required to

accommodate individuals of size), and A1.2-6.4.1.3 (Projecting the number of

expanded-capacity lifts required) to find suggestions for determining the number

of rooms per specific unit that should be able to accommodate individuals of size

and the need for expanded-capacity lifts. Useful information is provided in the

white paper “Patient Handling and Mobility Assessments, 2nd ed.” posted at

www.fgiguidelines.org.

Note: See the glossary for a definition of “individual of size.”

1.2-6.4.1 Projected Need for Accommodations for Care of Individuals of Size

The need for accommodations for care of individuals of size shall be defined in the planning phase and

shall include the following:

*1.2-6.4.1.1 Projected weight capacities for individuals of size in the population to be served

A1.2-6.4.1.1 Projecting the weight capacities of individuals of size to be

served. Projected weight capacities for the population of individuals of size are

necessary to make appropriate and accurate design decisions. The data and

methods described here can be used to project weight capacities for individuals

of size.

For new construction, CDC obesity prevalence data and future projections for a

specific geographic area may be used to drive estimates for the

accommodations—number of rooms; ceiling lift weight capacities; amount and

size of expanded-capacity furniture/equipment; additional space in patient,

examination/treatment, and other rooms, etc.—needed for patients who weigh

more than 300 pounds (136 kilograms). However, when planning renovations to

existing buildings or designing replacement hospitals, historical facility data

should also be used to forecast the accommodations needed for individuals of

size. Data should be obtained by clinical unit or area as opposed to gathering

facility-wide data. Estimates will be more accurate if at least one year’s worth of

data is used to obtain average figures.



For organizations without historical facility information, CDC prevalence and

future projections are helpful. This information can be found on these CDC

websites: www.cdc.gov/obesity/data/prevalence-maps.html and

http://nccd.cdc.gov/NPAO_DTM.

*1.2-6.4.1.2 Projected number of spaces required to accommodate individuals of size

A1.2-6.4.1.2 Projecting the number of spaces required to accommodate

individuals of size. When forecasting the number of rooms needed to

accommodate individuals of size, organizations should consider using the

following information:

—Average number of patients heavier than 300 pounds (136 kilograms) admitted

on a specific patient care unit each week or served in a specific clinical area

each week

—Average length of stay on each specific patient care unit for these patients

—CDC obesity prevalence future projections by geographic area

*1.2-6.4.1.3 Projected number of expanded-capacity lifts required

A1.2-6.4.1.3 Projecting the number of expanded-capacity lifts required.

Expanded-capacity ceiling lifts or wall-mounted lifts are the preferred methods

used to move patients. Ceiling or wall-mounted lifts require less space for

maneuvering than floor-based lifts. Details for design of patient rooms for

individuals of size are found in Section 2.1-2.3.2 (Accommodations for Care of

Individuals of Size—Patient Room).

Each facility may have a different weight threshold for expanded-capacity lifts,

but the suggested expanded-capacity threshold is at least 600 pounds (262

kilograms). The threshold is determined by the weight capacity of existing

standard capacity lifts used in the hospital, which often have a 600-pound (262-

kilogram) weight limit.

The projected number of expanded-capacity lifts needed is based on the projected

weight capacities for individuals of size in the population to be served (see

Section 1.2-6.4.1.1) and the projected number of spaces required to accommodate

these patients (see Section 1.2-6.4.1.2). When determining the number of

expanded-capacity lifts per unit, facilities should consider the following data:

—Average number of patients heavier than 600 pounds (262 kilograms) (or

facility threshold) admitted on a specific patient care unit each week or served

in a specific clinical area each week

—Average length of stay on each specific patient care unit for these patients

—CDC obesity prevalence future projections by geographic area

1.2-6.4.2 Design Response for Accommodations for Individuals of Size

A1.2-6.4.2 Design response for accommodations for care of individuals of

size



a. Accommodations for individuals of size and the equipment needed to care for

them require more operational space and more storage space than a traditional

patient care environment. The need for increased square footage will be

determined by the space needed for caregiver assistance and equipment to

accommodate individuals of size, both portable (e.g., beds, wheelchairs,

furniture, patient lifts) and fixed (e.g., large bore MRI/CT equipment, larger

surgical tables and exam tables).

Another primary space driver is the staffing-per-patient ratio and associated

maneuverability needed in environments where individuals of size are served. In

all instances, additional caregivers are recommended for patient handling.

b. Other design issues to consider when planning to accommodate individuals of

size include ingress/egress to primary treatment and service areas. The rooms

and/or destinations at the ends of these traverses also need special consideration

to accommodate the individuals of size:

—Surgical suites. The design needs to address issues that relate to patient

transfer, lifting, and holding for an extended period, proper and comfortable

positioning, and the most efficient positioning for the implementation of

surgical processes.

—Imaging suites. Many of the same issues found in a surgical environment,

especially patient transfer and positioning, are also present in the imaging

environment. It should be noted that much of the equipment associated with

imaging is not designed for individuals of size. Careful evaluation to ensure

selection of appropriate imaging equipment needs to be exercised.

—Exam rooms. Exam rooms should be programmed and sized to accommodate

the individual of size and the associated care team.

—Intensive care units. ICUs should be programmed and sized to accommodate

the individual of size and the associated care team.

—Waiting rooms or areas. Appropriately sized elements with capacity adequate

for individuals of size should be interspersed with more traditional furnishings

to avoid confining individuals of size to specific areas of the waiting

environment.

—Additional staff/patient interaction areas. These areas include

cashier/registration, patient assessment, food service, physical rehabilitation,

and family interaction areas.

1.2-6.4.2.1 The projected maximum weight of individuals of size who will require accommodations shall

determine the design requirements for sinks, toilets, grab bars, casework, and lifts in areas where

individuals of size will receive care.

1.2-6.4.2.2 Those areas of the facility designated for accommodations for individuals of size, and the

associated path of egress to reach these areas, shall be designed with appropriate support and clearances.

1.2-6.5 Emergency Preparedness and Management

During project planning and design, the following shall be considered:



*1.2-6.5.1 The likelihood that a facility will experience events that go beyond a facility’s normal

operations

A1.2-6.5.1 Emergency preparedness assessment. The likelihood that a facility

will experience events that go beyond normal operations should be assessed and

detailed in an annual emergency preparedness assessment. These events could

include natural disasters; utility failures; acts or threats of human violence;

biological, nuclear, or chemical exposures; surge capacity; infectious disease,

epidemic, or pandemic; evacuation; and mass casualties.

a. Infrastructure assessment. The assessment should consider performance of

structural and critical nonstructural building systems during an adverse event and

the likelihood of loss of externally supplied power, gas, water, and

communications from such a disaster.

b. Hospital facility planning. Ideally, the emergency preparedness assessment

results will be used to implement practices and plans that will help the health care

organization prevent, mitigate, and expediently recover from an event. Hospital

facility master planning should consider mitigation measures required to address

conditions that may be hazardous to patients and staff and conditions that may

compromise the ability of the hospital to fulfill its planned post-emergency

medical response.

Resiliency requires a plan to absorb and recover from adverse events by

preparing, preventing, protecting, mitigating, and responding. The plan should

outline a hospital’s ability to:

—Adapt to changing conditions, including surge conditions that necessitate use

of alternative sites

—Protect staff and patients

—Recover from disruptions

—Resist probable deliberate attacks

—Improve technical and organizational capabilities

—Focus on reducing damage and disruptions to public health and safety

c. Wind- and earthquake-resistant design for new buildings

—Facilities should be designed to meet the requirements of ASCE/SEI 7:

Minimum Design Loads for Buildings and Other Structures or building codes

with substantially equivalent requirements. Particular attention should be paid

to seismic considerations in areas where the classification of a building would

fall into seismic design categories C, D, E, or F as described in ASCE/SEI 7.

—Seismic construction inspection. The governing body should complete the

testing described in Section 11A.2 and special inspection during construction

of the seismic systems described in Section 11A.1.3 of ASCE/SEI 7.

—Roof considerations



• Roof coverings and mechanical equipment should be securely fastened or

ballasted to the supporting roof construction and provide weather

protection for the building at the roof. If ballast is used, it should be

designed so as not to become a projectile.

• In addition to the wind force design and construction requirements

specified, particular attention should be given to the design of roofing,

entryways, glazing, and flashing to minimize uplift, impact damage, and

other damage that could seriously impair building function.

d. Flood protection

— In accordance with Executive Order 11988 (Floodplain Management),

possible flood effects should be considered when selecting and developing the

site.

—Insofar as possible, new facilities should not be located on designated

floodplains.

—Where locating a facility on a floodplain is unavoidable, consult the U.S.

Army Corps of Engineers’ regional office for the latest applicable regulations

pertaining to required flood insurance and protection measures.

—Hospital helipads should be located a minimum of 3 feet (91.44 centimeters)

above the 100-year-flood elevation on campuses constructed on designated

floodplains. A path of travel above 100-year-flood elevation should be

provided between hospital acute care facilities and the helipad to facilitate

evacuation.

*1.2-6.5.2 Space needs in the event of an emergency for operations to:

A1.2-6.5.2 Space needs in an emergency. The location of the facility and the

type of event in the community may require a hospital to act as a shelter or

support other health care system needs. If so, the following should be considered

during planning:

a. Space where patients, staff, and visitors can be safe

b. Provision of space for resources needed to respond in an emergency, such as

medical supplies, materials, personal protective equipment, pharmaceuticals,

communications equipment, transportation, food, water, utilities, and waste

storage. Some of these resources could be accommodated through mutual aid

agreements between the health care organization and other local providers or

vendors. Such storage capacity or plans should be sufficient for at least four

continuous days of operation.

1.2-6.5.2.1 Protect facility occupants during the event.

*1.2-6.5.2.2 Continue providing services.

A1.2-6.5.2.2 Design for continued building system operation. For those

facilities that must remain operational, special design is required to protect

systems and essential building services such as power, water, medical gas



systems, and, in certain areas, air conditioning. In addition, special consideration

must be given to the likelihood of temporary loss of externally supplied power,

gas, water, and communications.

*1.2-6.6 Design Considerations for Palliative Care Settings

A1.2-6.6 Design considerations for palliative care. Palliative care is an

approach to clinical care that focuses on symptom management and

accommodations for and support of quality of life for the patient, their family and

friends, and their caregivers.

The following spaces and design characteristics should be considered based on

the care population being served:

a. Residential characteristics in a homelike setting to promote dignity and quality

of life for patients and visitors

b. Site features, clinical spaces, patient rooms, common spaces, and

administrative areas

c. Indoor and outdoor activity areas

d. Group meeting, educational, and therapy spaces for patients, family and

friends, and caregivers

e. Quiet rooms to allow for mitigation of excessive sensory stimulation

f. Positive auditory, olfactory, visual, and tactile elements enhanced by lighting

and acoustical systems

1.2-6.6.1 General

Where palliative care is provided, the following requirements shall be met:

*1.2-6.6.2 Location

A1.2-6.6.2 Settings. Palliative care may be provided in a variety of locations as a

service or in a designated setting, including a hospice facility.

1.2-6.6.2.1 Where a dedicated palliative care unit is provided, unrelated patient, staff, and public traffic

through the unit shall be prohibited except for emergency egress.

1.2-6.6.2.2 Where palliative care will be delivered outside of a dedicated palliative care unit, the palliative

care rooms shall be located to minimize unrelated patient, staff, and public traffic moving past these

rooms except for emergency egress.

*1.2-6.6.3 Accommodations for Individuals Receiving Palliative Care

A1.2-6.6.3 Accommodations for palliative care. Design for palliative care is

intended to convey comfort and well-being. Palliative care rooms should:

a. Minimize the institutional appearance of care and create a comfortable

environment with furniture, furnishings, and fixtures that are functional, safe, and

residential in appearance.



b. Allow patients to personalize their patient bedroom.

c. Be single-patient rooms to support patient and visitor privacy.

d. Reduce stressors for patients, friends and family, and caregivers (e.g., reduce

noise and glare and provide access to daylight).

*1.2-6.6.4 Support Spaces

Support spaces for family, visitors, and caregivers shall be provided.

A1.2-6.6.4 Support spaces for family, visitors, and caregivers. Support spaces

that are specific to the needs of family, visitors, and caregivers in the palliative

care setting should be provided. Consider provision of the following spaces.

a. Restorative break spaces. Restorative break spaces offer physical and mental

respite for caregivers and visitors in a private space that is removed from excess

audiovisual stimulation and foot traffic.

b. Relaxation spaces. This space should provide patients with cognitive

stimulation (e.g., games and activities), social stimulation (meeting spaces),

physical stimulation (ability to exercise and be active), and spiritual stimulation

(e.g., meditation and prayer).

c. Meeting spaces. Meeting spaces for formal physical, emotional, social, and

informal communication among family and caregivers.

d. Exterior and interior spaces. Exterior and interior spaces that support respite

should be included. These spaces may be shared.

1.2-6.6.5 Physical Environment Elements for Risk Reduction

See sections 1.2-4 (Safety Risk Assessment) and 1.2-5 (Environment of Care) for requirements.

1.2-7 Renovation

*1.2-7.1 Phasing

Projects involving renovation of existing buildings shall include phasing to minimize disruption of

existing patient services. This phasing is essential to ensure a safe environment in patient care areas.

A1.2-7.1 Phasing. Design documents for complex renovation projects should

include progressive phasing plans. These documents should clearly indicate and

delineate new work and existing conditions for each individual phase as the

project progresses. The interim impact to existing or proposed clinical services;

building services; patient, staff, and public circulation; and all required infection

control and interim life safety measures should be indicated for each phase.

1.2-7.1.1 Phasing Provisions

Phasing provisions shall include:

1.2-7.1.1.1 Clean-to-dirty airflow



1.2-7.1.1.2 Emergency procedures

1.2-7.1.1.3 Criteria for interruption of protection

1.2-7.1.1.4 Construction of roof surfaces

1.2-7.1.1.5 Written notification of interruptions

1.2-7.1.1.6 Communication authority

1.2-7.1.2 Noise and Vibration

Phasing plans shall include considerations of noise and vibration control during construction activities.

1.2-7.2 Isolation

During construction, renovation areas shall be isolated from occupied areas based on the ICRA; see

Section 1.2-4.2 (Infection Control Risk Assessment).

1.2-7.3 Maintenance of Air Quality and Utilities

Existing air quality requirements and utility requirements for occupied areas shall be maintained during

any renovation or construction.

*1.2-7.4 Existing Conditions

Existing conditions and operations shall be documented prior to initiation of renovation and new

construction projects. This shall include documentation of existing mechanical/electrical/structural

capacities and quantities.

A1.2-7.4 Existing conditions. Documentation of existing conditions should


a. Subsurface conditions (e.g., soil testing reports, soil types, known water table

information, active/abandoned utility locations)

b. Foundation and superstructure information, including the ability of the

structure and equipment (elevator) to handle the movement of heavy and/or large

loads from one location to another

c. Types of fire suppression, detection, and alarm systems, including whether the

building is fully sprinklered

d. Communications systems (e.g., telephone, nurse call, paging, telemetry,

dictation, electronic imaging systems)

e. Plumbing systems (e.g., domestic water, treated water, wastewater, pneumatic

tube, pneumatic controls, medical gases/vacuum systems)

f. Existing airflow of affected areas

g. Main electrical service and electrical service affected by construction,

including rating and actual load/peak and feeder sizes as applicable, and power

factor



h. Emergency power system, including rating and actual load/peak and feeder

sizes, as applicable, for life safety, emergency/critical, and equipment branches

*1.2-8 Commissioning

A1.2-8 Commissioning. Commissioning is a quality process used to achieve,

validate, and document that facilities and component infrastructure systems are

planned, constructed, installed, tested, and capable of being operated and

maintained in conformity with the design intent to meet the owner’s project

requirements (OPR).

a. Health facility commissioning. Many organizations, including NEBB, BCA,

and ASHE, have published commissioning manuals, guidelines, standards, and

handbooks. The ASHE Health Facility Commissioning Guidelines is structured

to foster a successful transition from planning, design, and construction to high-

performance operations (i.e., operations that are code-compliant, safe, and

energy-efficient and that support positive clinical outcomes and high patient and

visitor satisfaction).

The ASHE commissioning process includes the following unique features:

—Establishment of a project energy efficiency goal

—Involvement of health care facility operations and maintenance staff in the

design review process

—Development of a utility management plan (UMP) during the design process

instead of during the post-occupancy period

—Comprehensive training of the operations and maintenance staff, including

pre-testing to assess training needs and post-testing to ensure competency

—Testing of fire and smoke dampers prior to occupancy

—Measurement and verification of actual energy performance as compared to

the energy efficiency goal

b. Total building commissioning (TBC)

—Objective. TBC is a process whereby the governing body (i.e., the owner) is

assured that all building systems and components (not just the HVAC system)

will function according to design intent, specifications, equipment

manufacturers’ data sheets, and operational criteria. Because all building

systems are integrated and validated, the owner can expect the commissioning

process to improve occupant comfort, energy savings, environmental

conditions, system and equipment function, building operations and

maintenance, and building occupants’ productivity.

—Feedback. The TBC process should include a feedback mechanism that can be

incorporated into the owner’s postoccupancy evaluation process to enhance

future facility designs.



—Acceptance testing. Facility acceptance criteria should be based on the

commissioning requirements specified in the contract documents. These

criteria specify the tests, training, and reporting the owner must complete to

validate that each building system complies with the performance standards of

the basis of design before final acceptance of the facility.

—Systems and components included in TBC. Key systems and components that

should be tested and validated, at minimum, during the TBC process include

the design and operations of the HVAC, plumbing, electrical, emergency

power, fire protection/suppression, telecommunications, nurse call, intrusion

and other alarm device, and medical gas systems as well as specialty

equipment.

• Air balancing, pressure relationships, and exhaust criteria for mechanical

systems should be clearly described and tested to create an environment

of care that provides for infection control.

• Areas requiring emergency power should be specified and tested.

• Special plumbing systems should be certified to support the chemicals

scheduled for use in them.

• Water lines, taps, showers, and ice machines that have been disrupted or

stagnant should be flushed before use by building occupants.

c. Areas to be included in commissioning. While all areas of a hospital are

included in the commissioning process, areas of particular concern include

critical care units; surgical services; isolation rooms, including those used for

airborne infection/pathogens; and pharmacies and other areas potentially

containing hazardous substances.

1.2-8.1 Commissioning Requirements

On projects involving installation of new or modification to existing physical environment elements

critical to patient care and safety or facility energy use, at minimum the following systems shall be

commissioned:

1.2-8.1.1 HVAC

1.2-8.1.2 Automatic temperature control

1.2-8.1.3 Domestic hot water

1.2-8.1.4 Fire alarm and fire protection systems (integration with other systems)

1.2-8.1.5 Essential electrical power systems

1.2-8.1.6 Security systems

1.2-8.2 Commissioning Activities

At minimum, the following commissioning activities shall be undertaken:

1.2-8.2.1 Development of the Owner’s Project Requirements (OPR)



The governing body (i.e., the owner) shall develop the OPR.

*1.2-8.2.1.1 The OPR shall identify the building systems and elements to be commissioned as part of the

project scope.

A1.2-8.2.1.1 In addition to the minimum systems listed in 1.2-8.1

(Commissioning Requirements), consideration should be given to commissioning

the following systems:

a. Building envelope

b. Lighting controls and levels

c. Communication systems

d. Normal power systems

e. Plumbing systems

f. Acoustic measures

1.2-8.2.1.2 The OPR shall define the parameters required to meet the owner’s expectations, including the

following:

(1) Performance

(2) Operations

(3) Maintenance

(4) Longevity

(5) Energy efficiency

1.2-8.2.2 Preparation of the Basis of Design (BOD)

In response to the OPR, the design team shall prepare a BOD narrative describing the design intent and

systems to be commissioned. At minimum, the BOD narrative shall include the following elements:

1.2-8.2.2.1 Description of the systems, components, and methods used to meet the OPR

1.2-8.2.2.2 Diversity and safety factors used in sizing

1.2-8.2.2.3 Classes of systems and components planned (e.g., duct class, clean room class, etc.)

1.2-8.2.2.4 Levels of redundancy planned

1.2-8.2.2.5 Occupant density anticipated

1.2-8.2.2.6 Limitations and restrictions of systems and assemblies assumed

1.2-8.2.2.7 Indoor and outdoor conditions assumed (e.g., space temperature, relative humidity, lighting

power density, glazing fraction, U-value and shading coefficient, wall and ceiling R-values, ventilation

and infiltration rates, etc.)

1.2-8.2.2.8 Description of emergency operation intended



1.2-8.2.3 Preparation of Commissioning Plan, Commissioning Specifications, and Construction

Checklists

1.2-8.2.3.1 Commissioning plan. This document shall establish the scope, structure, and schedule of the

commissioning activities and address how the commissioning process will verify that the OPR and the

BOD are achieved.

1.2-8.2.3.2 Commissioning specifications

(1) General. These specifications shall establish requirements for physical environment elements to be

included in the project scope and identify responsibilities related to commissioning.

(2) Heated potable water distribution systems

(a) Design documents. The following shall be included in the design documents for both new

construction and renovation projects:

(i) Overview of the heated potable water system and its intended mode of system operation

(ii) Schematic diagrams of hot water systems

(iii) Locations of system access points, fill, makeup, flush points, sampling points, and

temperature monitoring and drain points, where applicable

(iv) Detailed instructions for commissioning of all building water systems, including procedures

for flushing and disinfection (including instructions that disinfection shall be completed

within two weeks of occupancy) and confirmation that building water system performance

meets design performance parameters documented in the design documents

(b) Installed system and equipment records. The following drawings and documents of the actual

installation of heated potable water systems and equipment shall be provided to the building owner

or designee:

(i) Location of each piece of equipment associated with the heated potable water system(s)

(ii) Diagram of the water distribution piping system, including system materials, pipe sizes,

design flow rates, design temperatures, temperature-monitoring points necessary to confirm

design temperatures throughout the system, fill provisions, blowdown provisions, makeup

provisions, and sampling points and drain provisions

(iii) Size and options for each piece of water system equipment

(iv) Applicable control system wiring diagrams, schematics, device locations, calibration

information, and operational sequences

(v) Material specifications for all building water system components

(vi) Material specifications for all water system insulation

(vii) Safety data sheets (SDSs) for applicable materials used for building water system treatment,

cleaning, flushing, disinfecting, and sealing

(viii) Installation requirements for all equipment

(ix) Start-up requirements for all equipment



(x) Operational requirements for all equipment and systems

*1.2-8.2.3.3 Construction checklists. These documents shall establish inspections and individual

component tests that will be used to verify proper functioning of physical environment elements that have

been installed or modified.

A1.2-8.2.3.3 Construction checklists. The commissioning agent provides

subcontractors with a list of items to inspect and elementary component tests to

conduct to verify proper installation of equipment. Items on construction

checklists are primarily static inspections and procedures to prepare the

equipment or system for initial operation (e.g., checking belt tension, oil levels,

labels affixed, gauges in place, sensors calibrated, etc.). However, some

construction checklist items entail simple testing of the function of a component,

a piece of equipment, or system (e.g., measuring the voltage imbalance of a

three-phase pump motor in a chiller system). Construction checklists augment

and are combined with the manufacturer’s start-up checklist. Even without a

commissioning process, contractors typically perform some, if not all, of the

construction checklist items on their own. The commissioning agent only

requires that the procedures be documented in writing and does not necessarily

witness much of the construction checklist testing, except for testing of larger or

more critical pieces or when desired by the owner.

*1.2-8.2.4 Performance of Functional/Operational Tests

Tests of the dynamic function and operation of the physical environment elements under full operation

shall be performed. Elements shall be tested in various modes and run through all sequences of operation.

A1.2-8.2.4 Functional operational/tests. Functional testing assesses the

dynamic function and operation of equipment and systems (rather than

components) under full operation using manual (direct observation) or

monitoring methods. (For example, the chiller pump is tested interactively with

the chiller functions to determine if the pump ramps up and down to maintain the

differential pressure setpoint.) Systems are tested in various modes, such as

during low cooling or heating loads, high loads, component failures, unoccupied

conditions, varying outside air temperatures, fire alarm activation, and power

failure. The systems are run through all the control system’s sequences of

operation, and the responses of components are verified to ensure they match

what the sequences state.

Traditional air or water testing and balancing (TAB) is not functional testing. The

primary purpose of TAB is to set up the system flows and pressures as specified.

Functional testing, on the other hand, is used to verify the performance of that

which has already been set up.

The commissioning agent develops the functional test procedures in a sequential

written form then coordinates, oversees, and documents the actual testing, which

is usually performed by the installing contractor or vendor. Functional tests are

performed after items on the construction checklists and startup procedures are

complete.

1.2-8.2.5 Preparation of the Commissioning Report

A commissioning report shall be prepared and presented to the owner to formally document the



following:

1.2-8.2.5.1 Performance of the physical environment elements

1.2-8.2.5.2 Performance issues identified

1.2-8.2.5.3 Mitigation or resolution of performance issues

1.2-8.2.5.4 Maintenance staff training to achieve operational sustainability

1.2-8.2.5.5 Compliance with the OPR and the BOD

*1.2-8.3 Commissioning Agent

Commissioning shall be led by any of the following as determined by the governing body:

A1.2-8.3 Commissioning agent. An independent commissioning agent with

health care experience compensated directly by the governing body and not

affiliated or associated with either the design team or the contractor should lead

the commissioning process. Use of an independent commissioning agent ensures

the commissioning agent is a focused owner advocate who can objectively

complete the commissioning tasks without any real or perceived conflict of

interest. It also should be noted that use of an independent commissioning agent

is encouraged by LEED criteria and required to earn the LEED point for

enhanced commissioning.

1.2-8.3.1 An independent commissioning agent with hospital experience and expertise

1.2-8.3.2 The design engineer

1.2-8.3.3 Another agent designated by the owner

1.2-9 Record Drawings and Manuals

1.2-9.1 Drawings

1.2-9.1.1 Record Drawings

Upon occupancy of the building or a portion thereof, the owner shall be provided with a complete set of

record documents that shows construction, fixed equipment, and mechanical, electrical, plumbing, and

structural systems and reflects known deviations from the construction documents.

1.2-9.1.2 Life Safety Overlay

Drawings shall include a life safety plan that reflects NFPA 101 requirements for each floor.

1.2-9.2 Equipment Manuals

1.2-9.2.1 Upon completion of the contract, the owner shall be furnished with the following for equipment

installed as part of the project:

1.2-9.2.1.1 A complete set of manufacturers’ operations, maintenance, and preventive maintenance

instructions for installed systems and equipment



1.2-9.2.1.2 Parts lists

1.2-9.2.1.3 Procurement information with numbers and a description for each piece of equipment

1.2-9.2.2 Operating staff shall be provided with instructions on how to properly operate systems and

equipment.

*1.2-9.3 Design Data

A1.2-9.3 The design data listed in Section 1.2-9.3 will be used to facilitate future

alterations, additions, and changes, including energy audits and retrofits for

energy conservation.

1.2-9.3.1 The owner shall be provided with complete design data for the facility, including the following:

1.2-9.3.1.1 Structural design loadings

1.2-9.3.1.2 Summary of heat loss assumption and calculations

1.2-9.3.1.3 Estimated water consumption

1.2-9.3.1.4 Medical gas outlet listing

1.2-9.3.1.5 List of applicable codes

1.2-9.3.1.6 Electric power requirements of installed equipment

1.2 planning, design, construction, and commissioning€¦ · commissioning of building water...

Documents